Healthcare Provider Details

I. General information

NPI: 1902357007
Provider Name (Legal Business Name): CATHERINE PROVENCAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 BAYVIEW TER
MILL VALLEY CA
94941-2496
US

IV. Provider business mailing address

15 BAYVIEW TER
MILL VALLEY CA
94941-2496
US

V. Phone/Fax

Practice location:
  • Phone: 415-717-3471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC 17247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: