MEDICARE: DR. FREDRIC P. PROVENZANO PH.D.

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	103T00000X	Psychologist	1022	WA

General Provider Information

NPI Number	:	1700932696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDRIC P. PROVENZANO PH.D.

Provider Business Mailing Address
First Line	:	5506 33RD AVE NE
Second Line	:	SUITE D
City	:	SEATTLE
State	:	WA
Zip	:	98105-2317
Country	:	US
Telephone Number	:	206-361-2343
Fax Number	:	206-361-0353

Provider Business Practice Location Address
First Line	:	5506 33RD AVE NE
Second Line	:	SUITE D
City	:	SEATTLE
State	:	WA
Zip	:	98105-2317
Country	:	US
Telephone Number	:	206-361-2343
Fax Number	:	206-361-0353

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	07/08/2007

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