Provider Demographics
NPI:1316196181
Name:ALLEN, TERESA (LAC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-6520
Practice Address - Street 1:2805 E ZION RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5195
Practice Address - Country:US
Practice Address - Phone:479-443-6496
Practice Address - Fax:479-443-2519
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0309085101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor