Provider Demographics
NPI:1699806877
Name:ALLEN, ANN MARIE (LADC INTENT)
Entity Type:Individual
Prefix:MISS
First Name:ANN
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LADC INTENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12120 BLUEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-1068
Mailing Address - Country:US
Mailing Address - Phone:405-246-6991
Mailing Address - Fax:
Practice Address - Street 1:2701 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2724
Practice Address - Country:US
Practice Address - Phone:405-528-8686
Practice Address - Fax:405-528-8692
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100742400BMedicaid
OK100742400FMedicaid
OK200363710AMedicaid