Provider Demographics
NPI:1457182214
Name:PROVENCIO, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 BOSCHERT CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-5951
Mailing Address - Country:US
Mailing Address - Phone:575-635-2516
Mailing Address - Fax:
Practice Address - Street 1:4554 LACLEDE AVE APT 308
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2147
Practice Address - Country:US
Practice Address - Phone:217-553-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP6047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist