Provider Demographics
NPI:1093199630
Name:ALLEN, GARRY (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 SAXON DR
Mailing Address - Street 2:
Mailing Address - City:ELKO NEW MARKET
Mailing Address - State:MN
Mailing Address - Zip Code:55054-4712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2345 ARIEL ST NORTH MAIL STOP 13601A
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-254-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5643103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical