Provider Demographics
NPI:1083796924
Name:ALLEN, MICHELE BASIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:BASIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 DESOTO ST
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3737
Mailing Address - Country:US
Mailing Address - Phone:228-872-8429
Mailing Address - Fax:228-872-0226
Practice Address - Street 1:904 DESOTO ST
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-872-8429
Practice Address - Fax:228-872-0226
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2018-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW732151041C0700X, 1041C0700X
MSC73051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05331761Medicaid