Provider Demographics
NPI:1558919043
Name:ALLEN, STEPHAN LEONARD
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:LEONARD
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 1:1186 PERIWINKLE PL
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8676
Mailing Address - Country:US
Mailing Address - Phone:305-409-7769
Mailing Address - Fax:
Practice Address - Street 1:1365 SW VIZCAYA CIR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-1962
Practice Address - Country:US
Practice Address - Phone:772-349-1186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-19-77532106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-19-77532OtherBACB