Provider Demographics
NPI:1255915070
Name:PROVOST, COURTNEY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PROVOST
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HERTEL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1906
Mailing Address - Country:US
Mailing Address - Phone:716-566-5050
Mailing Address - Fax:
Practice Address - Street 1:30 WILSON RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7026
Practice Address - Country:US
Practice Address - Phone:716-856-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06435267Medicaid
NY07014708Medicaid