Provider Demographics
NPI:1396228698
Name:ALLEN, DANIEL (LMT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6032 QUEENS WALK CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-7176
Mailing Address - Country:US
Mailing Address - Phone:571-316-4537
Mailing Address - Fax:
Practice Address - Street 1:4068 FLATS MAIN ST
Practice Address - Street 2:APT 100
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707
Practice Address - Country:US
Practice Address - Phone:703-863-9468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019016704225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty