Provider Demographics
NPI:1275697419
Name:ALLEN, VIVIETTE L
Entity Type:Individual
Prefix:
First Name:VIVIETTE
Middle Name:L
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 1:1318 RAEFORD RD
Mailing Address - Street 2:STE 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5096
Mailing Address - Country:US
Mailing Address - Phone:910-867-8889
Mailing Address - Fax:
Practice Address - Street 1:1540 PURDUE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:910-867-8889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1708103T00000X
NCCOO11421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10588OtherBCBS
NC6002468Medicaid
NCMEDCOSTOtherMEDCOST
NC344141OtherMHN TRICARE
NC10588OtherBCBS