Provider Demographics
NPI:1629810270
Name:PROVENCIO, AUGUSTINE (MS)
Entity type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:
Last Name:PROVENCIO
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2779 GOLDENROD CT
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-2772
Mailing Address - Country:US
Mailing Address - Phone:209-756-2632
Mailing Address - Fax:
Practice Address - Street 1:1339 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2033
Practice Address - Country:US
Practice Address - Phone:310-829-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent