Provider Demographics
NPI:1205336930
Name:ALLEN, DETERRENCE DEON (MS, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:DETERRENCE
Middle Name:DEON
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 MADELINE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6094
Mailing Address - Country:US
Mailing Address - Phone:334-524-6785
Mailing Address - Fax:
Practice Address - Street 1:2651 MADELINE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6094
Practice Address - Country:US
Practice Address - Phone:334-524-6785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1217103K00000X
AL2022-550103K00000X
MS180045103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst