Healthcare Provider Details

I. General information

NPI: 1295668341
Provider Name (Legal Business Name): MR. BRIAN PROVENCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CENTER ST
CHICOPEE MA
01013-2680
US

IV. Provider business mailing address

PO BOX 791
HOLYOKE MA
01041-0791
US

V. Phone/Fax

Practice location:
  • Phone: 413-540-1234
  • Fax: 413-538-5169
Mailing address:
  • Phone: 413-540-1234
  • Fax: 413-538-5169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: