Provider Demographics
NPI:1962993063
Name:ALLEN, NICOLE C
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
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 1:595 W EDGE TRL APT O
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6841
Mailing Address - Country:US
Mailing Address - Phone:317-981-0069
Mailing Address - Fax:
Practice Address - Street 1:595 W EDGE TRL APT O
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6841
Practice Address - Country:US
Practice Address - Phone:317-981-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCNA1001520103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service