Provider Demographics
NPI:1851813042
Name:ALLEN, DERIC (BCABA)
Entity Type:Individual
Prefix:
First Name:DERIC
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MESQUITE LN
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9519
Mailing Address - Country:US
Mailing Address - Phone:859-576-4178
Mailing Address - Fax:
Practice Address - Street 1:105 MESQUITE LN
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-9519
Practice Address - Country:US
Practice Address - Phone:859-576-4178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0-17-7944106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty