Provider Demographics
NPI:1861575508
Name:PROVOST, LISA MARIE (MA, LLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 DARWIN LN
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3456
Mailing Address - Country:US
Mailing Address - Phone:810-892-0784
Mailing Address - Fax:
Practice Address - Street 1:2360 S LINDEN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5420
Practice Address - Country:US
Practice Address - Phone:810-732-0560
Practice Address - Fax:810-732-6351
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010883103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical