Provider Demographics
NPI:1659952125
Name:FENDER, ALLEN (LMT)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:FENDER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57424 MEGAN DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57424 MEGAN DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-3816
Practice Address - Country:US
Practice Address - Phone:586-255-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist