Provider Demographics
NPI:1992264931
Name:ALLEN, ELIZABETH MARIE (LLMSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 1/2 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-8907
Mailing Address - Country:US
Mailing Address - Phone:312-339-9378
Mailing Address - Fax:
Practice Address - Street 1:4123 OKEMOS RD STE 15
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2818
Practice Address - Country:US
Practice Address - Phone:517-243-9738
Practice Address - Fax:517-913-5942
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011040031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801104003OtherLLMSW