Provider Demographics
NPI:1700932696
Name:PROVENZANO, FREDRIC P (PHD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:P
Last Name:PROVENZANO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5506 33RD AVE NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-2317
Mailing Address - Country:US
Mailing Address - Phone:206-361-2343
Mailing Address - Fax:206-361-0353
Practice Address - Street 1:5506 33RD AVE NE
Practice Address - Street 2:SUITE D
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-2317
Practice Address - Country:US
Practice Address - Phone:206-361-2343
Practice Address - Fax:206-361-0353
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1022103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB29993Medicare UPIN