Provider Demographics
NPI:1568401602
Name:ALLEN, BRUCE R (MSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:R
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-3527
Mailing Address - Country:US
Mailing Address - Phone:479-582-4422
Mailing Address - Fax:208-330-8228
Practice Address - Street 1:111 E DAVIDSON ST
Practice Address - Street 2:P.O. BX. 3724
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-3413
Practice Address - Country:US
Practice Address - Phone:479-582-4422
Practice Address - Fax:208-330-8228
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC0071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S033Medicare ID - Type Unspecified