MEDICARE: MS. LAUREN LUCIELLE PROVENCHER MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L2542834	MI

General Provider Information

NPI Number	:	1285918631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAUREN LUCIELLE PROVENCHER MSW

Provider Business Mailing Address
First Line	:	2301 12 MILE RD
Second Line	:
City	:	BERKLEY
State	:	MI
Zip	:	48072-1826
Country	:	US
Telephone Number	:	248-397-4705
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 12 MILE RD
Second Line	:
City	:	BERKLEY
State	:	MI
Zip	:	48072-1826
Country	:	US
Telephone Number	:	248-397-4705
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2011
Last Update Date	:	05/26/2026

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