Provider Demographics
NPI:1356540462
Name:PROVETTO, ALEXIS (PSYD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:PROVETTO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 POND VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-5200
Mailing Address - Country:US
Mailing Address - Phone:631-656-6411
Mailing Address - Fax:
Practice Address - Street 1:190 POND VIEW LN
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5200
Practice Address - Country:US
Practice Address - Phone:631-656-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020477103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical