Provider Demographics
NPI:1639854946
Name:ALLEN, MATT (CPSS)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WATERWORKS RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-8225
Mailing Address - Country:US
Mailing Address - Phone:606-224-7488
Mailing Address - Fax:
Practice Address - Street 1:159 WATERWORKS RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8225
Practice Address - Country:US
Practice Address - Phone:606-224-7488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist