Provider Demographics
NPI:1588644918
Name:ALLEN, KEITH (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LMSW
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 115
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0115
Mailing Address - Country:US
Mailing Address - Phone:602-528-1340
Mailing Address - Fax:602-518-1296
Practice Address - Street 1:483 W. SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-1340
Practice Address - Fax:602-528-1296
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2970104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8EB637,38,39Medicare ID - Type Unspecified