Provider Demographics
NPI:1740790765
Name:ALLEN, SHIRLEY B
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:B
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 EDEN LN
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-6036
Mailing Address - Country:US
Mailing Address - Phone:605-415-0792
Mailing Address - Fax:
Practice Address - Street 1:4110 WINFIELD CT
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-8306
Practice Address - Country:US
Practice Address - Phone:605-415-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD82-2789782OtherDEPTPARTMENT OF TREASURY
SDDL137092OtherSOUTH DAKOTA SECRETARY OF STATE