Provider Demographics
NPI:1538790134
Name:PROVENCIAL, RICHARD RUSSELL (CAS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:RUSSELL
Last Name:PROVENCIAL
Suffix:
Gender:M
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5360 S ELATI ST APT 6
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-1527
Mailing Address - Country:US
Mailing Address - Phone:720-249-8862
Mailing Address - Fax:
Practice Address - Street 1:2993 S PEORIA ST STE G5
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-5705
Practice Address - Country:US
Practice Address - Phone:720-249-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0998145101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)