Provider Demographics
NPI:1386856516
Name:SUMMERVILLE, ALLEN F SR (LSW)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:F
Last Name:SUMMERVILLE
Suffix:SR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLBY AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1000
Mailing Address - Country:US
Mailing Address - Phone:856-541-1700
Mailing Address - Fax:856-346-3627
Practice Address - Street 1:1 COLBY AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1000
Practice Address - Country:US
Practice Address - Phone:856-541-1700
Practice Address - Fax:856-346-3627
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SL05365800OtherLSW