MEDICARE: MS. ELIZABETH PROVOST LCSW

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	12449	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871773440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH PROVOST LCSW

Provider Business Mailing Address
First Line	:	1620 GREEN MEADOW LN
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-5319
Country	:	US
Telephone Number	:	830-822-2361
Fax Number	:

Provider Business Practice Location Address
First Line	:	1620 GREEN MEADOW LN
Second Line	:
City	:	SPRING BRANCH
State	:	TX
Zip	:	78070-5319
Country	:	US
Telephone Number	:	830-822-2361
Fax Number	:

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

Provider Enumeration Date	:	11/12/2007
Last Update Date	:	08/26/2013

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