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Individual

SHARAYAH K PROVOST

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
LPC

Contact information

Practice address
16535 W BLUEMOUND RD STE 305, BROOKFIELD, WI 53005-5936
(800) 438-1770
(262) 345-5562
Mailing address
W175N11120 STONEWOOD DR, GERMANTOWN, WI 53022-6511
(800) 438-1772
(262) 293-9737

Taxonomy

Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
3367-226
WI
101YP2500X
Professional Counselor
Primary
7206-125
WI

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
100084565
WI
Enumeration date
12/26/2018
Last updated
02/10/2020
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