Provider Demographics
NPI:1811793813
Name:PROVENCHER, MICHAEL JOSEPH JR (LGPC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:PROVENCHER
Suffix:JR
Gender:
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:117 CENTRAL AVE.
Mailing Address - City:GLYNDON
Mailing Address - State:MD
Mailing Address - Zip Code:21071
Mailing Address - Country:US
Mailing Address - Phone:443-244-1860
Mailing Address - Fax:
Practice Address - Street 1:117 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLYNDON
Practice Address - State:MD
Practice Address - Zip Code:21071-4208
Practice Address - Country:US
Practice Address - Phone:443-244-1886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15969101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health