Provider Demographics
NPI:1760802482
Name:ALLEN, CHARLES RANDALL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RANDALL
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 VETERANS DR SW
Mailing Address - Street 2:A-122-SW-BLDG 148
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-2735
Mailing Address - Country:US
Mailing Address - Phone:253-583-3178
Mailing Address - Fax:253-589-4035
Practice Address - Street 1:9600 VETERANS DR SW
Practice Address - Street 2:A-122-SW-BLDG 148
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-2735
Practice Address - Country:US
Practice Address - Phone:253-583-3178
Practice Address - Fax:253-583-3178
Is Sole Proprietor?:No
Enumeration Date:2014-04-21
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical