Provider Demographics
NPI:1114409877
Name:ALLEN, DONNA MORIARTY
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MORIARTY
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 RADCLIFFE RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-3340
Mailing Address - Country:US
Mailing Address - Phone:617-484-0937
Mailing Address - Fax:
Practice Address - Street 1:84 RADCLIFFE RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-3340
Practice Address - Country:US
Practice Address - Phone:617-484-0937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10178421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1017942OtherSW LICENSE