Provider Demographics
NPI:1083058523
Name:ALLEN, MONGO (M ED)
Entity Type:Individual
Prefix:
First Name:MONGO
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 NW 142ND ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1962
Mailing Address - Country:US
Mailing Address - Phone:405-242-3423
Mailing Address - Fax:
Practice Address - Street 1:829 NW 142ND ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1962
Practice Address - Country:US
Practice Address - Phone:405-315-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-27
Last Update Date:2013-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness