Provider Demographics
NPI:1205267838
Name:ALLEN, DOMINICK CHARLES (LCSW)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:CHARLES
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:DOMINICK
Other - Middle Name:CHARLES ALLEN
Other - Last Name:MAXEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4212 SE DIVISION ST STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1680
Practice Address - Country:US
Practice Address - Phone:503-238-0705
Practice Address - Fax:503-236-7166
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-08
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner