Provider Demographics
NPI:1245833409
Name:PROVENCHER, PEYTON RYLEY
Entity type:Individual
Prefix:
First Name:PEYTON
Middle Name:RYLEY
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HOMER SQ
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3003
Mailing Address - Country:US
Mailing Address - Phone:207-835-9007
Mailing Address - Fax:
Practice Address - Street 1:5 CONSTITUTION WAY STE 6
Practice Address - Street 2:
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1199
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health