Provider Demographics
NPI:1043202310
Name:ALLEN, WENDY (OTR/L)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1029A HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-9768
Mailing Address - Country:US
Mailing Address - Phone:662-241-4545
Mailing Address - Fax:662-241-4025
Practice Address - Street 1:65 DUTCH LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39702-5523
Practice Address - Country:US
Practice Address - Phone:662-241-4545
Practice Address - Fax:662-241-4025
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1193225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04885392Medicaid
MS04885392Medicaid
MS670000042Medicare ID - Type Unspecified