Provider Demographics
NPI:1396303632
Name:PROVENCE, JOY E
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:E
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16133 N 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-1362
Mailing Address - Country:US
Mailing Address - Phone:623-547-9646
Mailing Address - Fax:
Practice Address - Street 1:1000 E NARRAMORE AVE
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-2632
Practice Address - Country:US
Practice Address - Phone:623-386-9708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-12558101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional