Provider Demographics
NPI:1922322403
Name:ALLEN, TERI (LISW)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 WHITTINGTON PL
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-9270
Mailing Address - Country:US
Mailing Address - Phone:915-588-7290
Mailing Address - Fax:575-613-7243
Practice Address - Street 1:2410 S ESPINA ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5612
Practice Address - Country:US
Practice Address - Phone:915-588-7290
Practice Address - Fax:575-613-7243
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-05502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM58446368Medicaid
NM264729YLCWMedicare UPIN