Provider Demographics
NPI:1487196259
Name:ALLEN, GRUNDI R (LICDC)
Entity Type:Individual
Prefix:MS
First Name:GRUNDI
Middle Name:R
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5932 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224-2378
Mailing Address - Country:US
Mailing Address - Phone:513-961-4663
Mailing Address - Fax:513-961-4681
Practice Address - Street 1:5932 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-2378
Practice Address - Country:US
Practice Address - Phone:513-961-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.141166101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)