Provider Demographics
NPI:1457068413
Name:PROVOST, MICHELLE L (LPC, CHT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:L
Last Name:PROVOST
Suffix:
Gender:F
Credentials:LPC, CHT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:PROVOST-WASSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6315 KIPS LN
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-9788
Mailing Address - Country:US
Mailing Address - Phone:803-347-8600
Mailing Address - Fax:
Practice Address - Street 1:6315 KIPS LN
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-9788
Practice Address - Country:US
Practice Address - Phone:803-347-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6216101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6216OtherLICENSE NUMBER