Provider Demographics
NPI:1497729479
Name:ALLEN, MARY (MLSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MLSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5539 BAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-9211
Mailing Address - Country:US
Mailing Address - Phone:231-690-4889
Mailing Address - Fax:
Practice Address - Street 1:5539 BAR LAKE RD
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9211
Practice Address - Country:US
Practice Address - Phone:231-690-4889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010168301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801016830OtherSTATE LICENSE NUMBER
MIMA016830Other3RD PARTY IDENTIFIER
MI6801016830OtherSTATE LICENSE NUMBER