1942625165 NPI number — MISS SHANTANA SUE ALLEN LPC

Table of content: MISS SHANTANA SUE ALLEN LPC (NPI 1942625165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942625165 NPI number — MISS SHANTANA SUE ALLEN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
SHANTANA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1942625165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4502 E 41ST ST STE 1202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74135-2536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-660-3150
Provider Business Mailing Address Fax Number:
918-660-3143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4502 E 41ST ST
Provider Second Line Business Practice Location Address:
OU IMPACT
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74135-2536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-660-3150
Provider Business Practice Location Address Fax Number:
918-660-3143
Provider Enumeration Date:
02/25/2014

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: 101YP2500X , with the licence number:  6166 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200532970A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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