Provider Demographics
NPI:1659500882
Name:ALLEN, MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1720
Mailing Address - Country:US
Mailing Address - Phone:608-449-7201
Mailing Address - Fax:
Practice Address - Street 1:113 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1720
Practice Address - Country:US
Practice Address - Phone:608-449-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8198-1231041C0700X
CALCS291091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16-59500882Medicaid
CAHE611AOtherMEDICARE PART B PROVIDER PTAN
WILCSW 8198-123OtherSTATE OF WISC-DEPT OF SAFETY & PROFESSIONAL SERVICES
CALCS29109OtherBOARD OF BEHAVIORAL SCIENCE