Provider Demographics
NPI:1821515198
Name:ALLEN, MICTISSA
Entity Type:Individual
Prefix:
First Name:MICTISSA
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICTISSA
Other - Middle Name:
Other - Last Name:MOSELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4628 BLUERIBBON DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70814-8035
Mailing Address - Country:US
Mailing Address - Phone:225-636-3270
Mailing Address - Fax:
Practice Address - Street 1:3084 WESTFORK DR STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2254
Practice Address - Country:US
Practice Address - Phone:225-296-6083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-27
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health