1073605945 NPI number — RICHARD J PROVENZANO LCSW

Table of content: RICHARD J PROVENZANO LCSW (NPI 1073605945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073605945 NPI number — RICHARD J PROVENZANO LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROVENZANO
Provider First Name:
RICHARD
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073605945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 193
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22664-0193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-335-3715
Provider Business Mailing Address Fax Number:
540-459-9015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22664-1451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-335-3715
Provider Business Practice Location Address Fax Number:
540-459-9015
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904002158 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 089598M . This is a "OUTPATIENT THERAPY-OPTIMA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010278520 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 197389 . This is a "OUTPATIENT THERAPY-ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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