Provider Demographics
NPI:1003023680
Name:ALLEN, ANTHONY JEROME (AAS, CAC II)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JEROME
Last Name:ALLEN
Suffix:
Gender:M
Credentials:AAS, CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 BANGOR ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48210-1760
Mailing Address - Country:US
Mailing Address - Phone:313-867-1090
Mailing Address - Fax:313-867-0706
Practice Address - Street 1:12010 LINWOOD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-1108
Practice Address - Country:US
Practice Address - Phone:313-867-1090
Practice Address - Fax:313-867-0706
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820202101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)