Provider Demographics
NPI:1033231592
Name:ALLEN, STEPHANIE L (THERAPIST)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:ALLEN
Suffix:
Gender:F
Credentials:THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 OLD HICKORY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4551
Mailing Address - Country:US
Mailing Address - Phone:731-499-2318
Mailing Address - Fax:731-499-2318
Practice Address - Street 1:49 OLD HICKORY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-4551
Practice Address - Country:US
Practice Address - Phone:731-499-2318
Practice Address - Fax:731-499-2318
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TNLSW00000064561041C0700X
TN29226581041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool