Provider Demographics
NPI:1588750053
Name:ALLEN, ROBERTA MANESS (MSW)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MANESS
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MSW
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 728
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-4728
Mailing Address - Country:US
Mailing Address - Phone:410-544-2287
Mailing Address - Fax:410-544-4663
Practice Address - Street 1:110 GLEN OBAN DR
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2101
Practice Address - Country:US
Practice Address - Phone:410-544-2287
Practice Address - Fax:410-544-4663
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD025581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410194-02OtherBC/BS RENDERING PROVIDER#
MDQD31RMOtherPROVIDER NUMBER
MDR9200001OtherFEDERAL BC/BS PROVIDER#
MD283036000OtherMAGELLAN PROVIDER #
MD643QMedicare ID - Type Unspecified