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General NPI Number Information
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NPI Number | 1730682410
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Entity Type | Individual
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Provider Name | GRAYDEN BOYD PROVANCE
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Gender | Male
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Dates
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Enumeration Date | 03/09/2018
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Last Update Date | 03/09/2018
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Provider Practice Location Address
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Address Line | 400 TUSCARAWAS ST W
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City | CANTON
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State | OH
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Zip | 44702-2044
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Country | US
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Telephone | 330-438-2400
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Fax | 330-438-3003
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Provider Business Mailing Address
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Address Line | 5982 RHODES RD
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City | KENT
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State | OH
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Zip | 44240-8100
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Country | US
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Telephone | 330-673-1347
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Fax | 330-678-3677
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 00495
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License Number State | OH
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