Provider Demographics
NPI:1730069352
Name:PROVANCE, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:PROVANCE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PEVELY
Mailing Address - State:MO
Mailing Address - Zip Code:63070-2053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 LEON HALL PKWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-3419
Practice Address - Country:US
Practice Address - Phone:636-789-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025023353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist