Provider Demographics
NPI:1962755009
Name:PROVOOST, DENISE (PTA)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:PROVOOST
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 CALIFORNIA STREET
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-249-9698
Mailing Address - Fax:
Practice Address - Street 1:1515 EUBANK BLVD SE BLDG 832
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87185
Practice Address - Country:US
Practice Address - Phone:505-844-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA0714225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant