Provider Demographics
NPI:1619107505
Name:ALLEN, REVA I (PHD, LISW)
Entity Type:Individual
Prefix:DR
First Name:REVA
Middle Name:I
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PHD, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4132 WILLYS PKWY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1649
Mailing Address - Country:US
Mailing Address - Phone:419-367-8708
Mailing Address - Fax:
Practice Address - Street 1:4132 WILLYS PKWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1649
Practice Address - Country:US
Practice Address - Phone:419-367-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-25
Last Update Date:2009-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI09000351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical