Provider Demographics
NPI:1972715738
Name:PROVENCHER, ANNETTE CECILE (MSW LCSW)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:CECILE
Last Name:PROVENCHER
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 CHAPMAN TER
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-1563
Mailing Address - Country:US
Mailing Address - Phone:732-615-2359
Mailing Address - Fax:
Practice Address - Street 1:210 BROAD ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2060
Practice Address - Country:US
Practice Address - Phone:732-876-3094
Practice Address - Fax:732-615-2359
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC048231001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ073013Medicare ID - Type Unspecified