Provider Demographics
NPI:1063431443
Name:ALLEN, FRED (LISW)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 KENWOOD AVE.
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415
Mailing Address - Country:US
Mailing Address - Phone:937-277-1592
Mailing Address - Fax:
Practice Address - Street 1:28 E RAHN RD
Practice Address - Street 2:SUTIE 105
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-5461
Practice Address - Country:US
Practice Address - Phone:937-434-6840
Practice Address - Fax:937-264-1101
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-7931101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health