Provider Demographics
NPI:1003837568
Name:ALLEN, VIRGINIA A (LISW)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:A
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-3803
Mailing Address - Country:US
Mailing Address - Phone:505-445-7090
Mailing Address - Fax:505-445-7663
Practice Address - Street 1:101 N 2ND ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3803
Practice Address - Country:US
Practice Address - Phone:505-445-7090
Practice Address - Fax:505-445-7663
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-057431041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58230882Medicaid