Provider Demographics
NPI:1124442421
Name:ALLEN, CARLETTA JEAN
Entity type:Individual
Prefix:
First Name:CARLETTA
Middle Name:JEAN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 137
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-0137
Mailing Address - Country:US
Mailing Address - Phone:208-962-3251
Mailing Address - Fax:208-962-2478
Practice Address - Street 1:701 LEWISTON STREET
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522
Practice Address - Country:US
Practice Address - Phone:208-962-3251
Practice Address - Fax:208-962-2478
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1091235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist