Provider Demographics
NPI:1114558236
Name:ALLEN, STEPHANIE EDWARDS
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:EDWARDS
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 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:
Practice Address - Street 1:847 W LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2157
Practice Address - Country:US
Practice Address - Phone:336-783-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0142821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical