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1629810270
AUGUSTINE PROVENCIO
SANTA MONICA, CA
NPI
1629810270
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Entity Type
Individual
Gender
Male
Sole Proprietor ?
Yes
Primary Taxonomy
103TC2200X Psychologist Clinical Child & Adolescent
Enumeration Date
2024-06-12
Last Update Date
2024-06-12
Business Address
AUGUSTINE PROVENCIO MS
1339 20TH ST
SANTA MONICA, CA 90404-2033
Phone number: 310-829-8708
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Mailing Address
AUGUSTINE PROVENCIO MS
2779 GOLDENROD CT
MERCED, CA 95340-2772
Phone number: 209-756-2632
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