Provider Demographics
NPI:1467068320
Name:PROVAN, HALEY KENDALL
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:KENDALL
Last Name:PROVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8885 RIO SAN DIEGO DR STE 367
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1655
Mailing Address - Country:US
Mailing Address - Phone:858-232-6266
Mailing Address - Fax:
Practice Address - Street 1:8885 RIO SAN DIEGO DR STE 367
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1655
Practice Address - Country:US
Practice Address - Phone:858-232-6266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA147097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist