Provider Demographics
NPI:1205859006
Name:ALLEN, GEORGE DAVID (PHD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:DAVID
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 MAPLE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-0809
Mailing Address - Country:US
Mailing Address - Phone:304-599-5751
Mailing Address - Fax:
Practice Address - Street 1:1062 MAPLE DR STE 1
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-0809
Practice Address - Country:US
Practice Address - Phone:304-599-5751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV725103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0165165000Medicaid
WV000132232OtherMT. STATE BC/BS