Individual
LARRY G PROVENCE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.A., L.P.C.
Contact information
Practice address
4715 N STAGE WAY LN, PRESCOTT VALLEY, AZ 86314-5325
(928) 775-0019
Mailing address
4715 N STAGE WAY LN, PRESCOTT VALLEY, AZ 86314-5325
(928) 775-0019
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
LPC11598
AZ
Other
Enumeration date
11/29/2007
Last updated
11/29/2007
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