Provider Demographics
NPI:1942839733
Name:ALLEN, MARLA BETH
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:BETH
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 1:416 MOSLEY DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-3113
Mailing Address - Country:US
Mailing Address - Phone:785-821-6024
Mailing Address - Fax:
Practice Address - Street 1:8282 WILLETT PKWY
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-1306
Practice Address - Country:US
Practice Address - Phone:315-857-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180147571103TS0200X
KS7324878156103TS0200X
NY2898866103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool