Provider Demographics
NPI:1457139222
Name:PROVAZZA, KYLA (BS)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:
Last Name:PROVAZZA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 REGENT DR UNIT 222
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3070
Mailing Address - Country:US
Mailing Address - Phone:603-828-6640
Mailing Address - Fax:
Practice Address - Street 1:200 ROUTE 108 # 108
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-1119
Practice Address - Country:US
Practice Address - Phone:603-953-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)