Provider Demographics
NPI:1023179116
Name:ALLEN, STANLEY MICHAEL EUGENE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:MICHAEL EUGENE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 KAY LN NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3111
Mailing Address - Country:US
Mailing Address - Phone:404-219-5821
Mailing Address - Fax:
Practice Address - Street 1:1770 INDIAN TRAIL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2645
Practice Address - Country:US
Practice Address - Phone:770-923-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0007071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA032860193AMedicaid