Provider Demographics
NPI:1801078027
Name:PROVENCE, LARRY G (MA, LPC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:G
Last Name:PROVENCE
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4715 N STAGE WAY LN
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-5325
Mailing Address - Country:US
Mailing Address - Phone:928-775-0019
Mailing Address - Fax:
Practice Address - Street 1:4715 N STAGE WAY LN
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-5325
Practice Address - Country:US
Practice Address - Phone:928-775-0019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC11598101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional