Provider Demographics
NPI:1427710888
Name:PROVANCAL, LAURITA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:LAURITA
Middle Name:MARIE
Last Name:PROVANCAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 OGDEN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4284
Mailing Address - Country:US
Mailing Address - Phone:630-256-8007
Mailing Address - Fax:
Practice Address - Street 1:1900 OGDEN AVE STE 106
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4284
Practice Address - Country:US
Practice Address - Phone:630-256-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490026771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical