Provider Demographics
NPI:1215235031
Name:ALLEN, SUSAN KAY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LCSW
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 353
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-0353
Mailing Address - Country:US
Mailing Address - Phone:406-303-0397
Mailing Address - Fax:406-721-5912
Practice Address - Street 1:415 N HIGGINS
Practice Address - Street 2:SUITE 4
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4559
Practice Address - Country:US
Practice Address - Phone:406-303-0397
Practice Address - Fax:406-721-5912
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT630104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011006202OtherMEDICARE PTAN