Provider Demographics
NPI:1639854946
Name:ALLEN, MATT (CPSS)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 WATERWORKS RD
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-8225
Mailing Address - Country:US
Mailing Address - Phone:606-224-7488
Mailing Address - Fax:
Practice Address - Street 1:565 HIGHWAY 192 W
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2637
Practice Address - Country:US
Practice Address - Phone:606-224-7488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
KY288501101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No174400000XOther Service ProvidersSpecialist