Individual
AUGUSTINE PROVENCIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MS
Contact information
Practice address
4650 W SUNSET BLVD # 53, LOS ANGELES, CA 90027-6062
(323) 361-3849
Mailing address
2779 GOLDENROD CT, MERCED, CA 95340-2772
(209) 756-2632
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
103TC2200X
Clinical Child & Adolescent Psychologist
—
—
Other
Enumeration date
06/12/2024
Last updated
08/27/2025
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