1659500882 NPI number — MARY ALLEN LCSW

Table of content: MARY ALLEN LCSW (NPI 1659500882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659500882 NPI number — MARY ALLEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659500882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOUGHTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53589-1720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-449-7201
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53589-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-449-7201
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  8198-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCS29109 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16-59500882 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: HE611A . This is a "MEDICARE PART B PROVIDER PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LCSW 8198-123 . This is a "STATE OF WISC-DEPT OF SAFETY & PROFESSIONAL SERVICES" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: LCS29109 . This is a "BOARD OF BEHAVIORAL SCIENCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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