Provider Demographics
NPI:1386099075
Name:ALLEN, EUTELYN
Entity type:Individual
Prefix:
First Name:EUTELYN
Middle Name:
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 1:174 SE SERENATA CT
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2137
Mailing Address - Country:US
Mailing Address - Phone:772-342-7706
Mailing Address - Fax:
Practice Address - Street 1:2814 S US HIGHWAY 1 STE D4
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-8110
Practice Address - Country:US
Practice Address - Phone:772-489-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool