Provider Demographics
NPI:1285163709
Name:ALLEN, SHERRITA M
Entity type:Individual
Prefix:
First Name:SHERRITA
Middle Name:M
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 1:15405 COUSTEAU DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2254
Mailing Address - Country:US
Mailing Address - Phone:417-300-3386
Mailing Address - Fax:
Practice Address - Street 1:104 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3301
Practice Address - Country:US
Practice Address - Phone:417-588-5885
Practice Address - Fax:417-588-4296
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017010257101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty