Healthcare Provider Details

I. General information

NPI: 1679002489
Provider Name (Legal Business Name): KRISTEN PROVOST LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 N CLARE AVE
HARRISON MI
48625-8250
US

IV. Provider business mailing address

789 N CLARE AVE
HARRISON MI
48625-8250
US

V. Phone/Fax

Practice location:
  • Phone: 989-539-2141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801100935
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: