Provider Demographics
NPI:1134459548
Name:ALLEN, STACEY LYN (CSW)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:LYN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:CSW
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 2106
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2106
Mailing Address - Country:US
Mailing Address - Phone:208-360-2850
Mailing Address - Fax:
Practice Address - Street 1:1675 CURLEW DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4718
Practice Address - Country:US
Practice Address - Phone:208-523-5319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-30182101Y00000X, 101YM0800X, 104100000X, 1041C0700X
ID352791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker