IAN VICTOR PROVO

ROCKFORD, IL
NPI1235614124
Professional NameIAN VICTOR PROVO
Entity TypeIndividual
GenderMale
Sole Proprietor ?Yes
Primary Taxonomy1041C0700X Social Worker, Clinical
(Licence: IL  149006049)
Enumeration Date2018-09-26
Last Update Date2018-09-26
Business Address
IAN VICTOR PROVO
1126 POST DR
ROCKFORD, IL 61108-4251
Phone number: 815-229-3738
Mailing Address
IAN VICTOR PROVO
1126 POST DR
ROCKFORD, IL 61108-4251
Phone number: 815-229-3738
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