Provider Demographics
NPI:1306194725
Name:ALLEN, WENONA
Entity Type:Individual
Prefix:
First Name:WENONA
Middle Name:
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 1:1724 MLK BLVD
Mailing Address - Street 2:1724 MLK
Mailing Address - City:MIDWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32343
Mailing Address - Country:US
Mailing Address - Phone:850-294-4254
Mailing Address - Fax:
Practice Address - Street 1:1724 MLK BLVD
Practice Address - Street 2:1724 MLK
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343
Practice Address - Country:US
Practice Address - Phone:850-294-4254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist