Provider Demographics
NPI:1669575247
Name:JANEEN PROVAZEK MA PS
Entity type:Organization
Organization Name:JANEEN PROVAZEK MA PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND ONLY EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:JANEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVAZEK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:253-851-6178
Mailing Address - Street 1:5800 SOUNDVIEW DR
Mailing Address - Street 2:STE 101-D
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-2077
Mailing Address - Country:US
Mailing Address - Phone:253-851-6178
Mailing Address - Fax:253-851-6199
Practice Address - Street 1:5800 SOUNDVIEW DR
Practice Address - Street 2:STE 101-D
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-2077
Practice Address - Country:US
Practice Address - Phone:253-851-6178
Practice Address - Fax:253-851-6199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001337106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty