Provider Demographics
NPI:1962436519
Name:PROVOST, MATTHEW P (MS,CCC-SLP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:PROVOST
Suffix:
Gender:M
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 COMSTOCK PKWY
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-2002
Mailing Address - Country:US
Mailing Address - Phone:401-463-0202
Mailing Address - Fax:
Practice Address - Street 1:161 COMSTOCK PKWY
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02921-2002
Practice Address - Country:US
Practice Address - Phone:401-463-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RISP00739235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4600103OtherSS UHP
RI9009994Medicaid
RI411302OtherSS BCHIP
RI2058OtherSS NHPRC
RI99947OtherSS BCROSS