Individual
LISA MARIE PROVOST
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MA, LLP
Contact information
Practice address
2360 S LINDEN RD, SUITE 300, FLINT, MI 48532-5420
(810) 732-0560
(810) 732-6351
Mailing address
2420 DARWIN LN, SAGINAW, MI 48603-3456
(810) 892-0784
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
6301010883
MI
Other
Enumeration date
10/24/2006
Last updated
07/08/2007
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