Provider Demographics
NPI:1316141476
Name:ALLEN, MARY ELENA (MED,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELENA
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:227 HAMPTON SHORES DRIVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228
Mailing Address - Country:US
Mailing Address - Phone:678-479-6002
Mailing Address - Fax:678-479-9630
Practice Address - Street 1:227 HAMPTON SHORES DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-2762
Practice Address - Country:US
Practice Address - Phone:678-479-6002
Practice Address - Fax:678-479-9630
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP 005884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist