Individual
MAI LE PROVENCIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
7235 W POTOMAC DR STE 220, BOISE, ID 83704-9133
(208) 794-9703
Mailing address
7235 W POTOMAC DR STE 220, BOISE, ID 83704-9133
(208) 576-0571
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
LCSW-34323
ID
Other
Enumeration date
01/11/2017
Last updated
10/23/2024
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