Provider Demographics
NPI:1548203698
Name:ALLEN, SAMUEL S
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:S
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3381
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-3381
Mailing Address - Country:US
Mailing Address - Phone:919-313-0260
Mailing Address - Fax:
Practice Address - Street 1:2609 N DUKE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-3019
Practice Address - Country:US
Practice Address - Phone:919-313-0260
Practice Address - Fax:919-313-0299
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2904101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2342249OtherGROUP MEDICARE