Provider Demographics
NPI:1376628545
Name:ALLEN, ROBERTA LOU (LMSW-ACP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LOU
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LMSW-ACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CANYON RIM DR
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-1719
Mailing Address - Country:US
Mailing Address - Phone:806-674-3338
Mailing Address - Fax:806-655-0518
Practice Address - Street 1:3131 BELL ST STE 110
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-5029
Practice Address - Country:US
Practice Address - Phone:806-355-0515
Practice Address - Fax:806-355-0546
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX063912201Medicaid