Provider Demographics
NPI:1235690959
Name:ALLEN, WANDA ANITA
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:ANITA
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 1:1700 AUTUMNWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-1704
Mailing Address - Country:US
Mailing Address - Phone:931-436-3213
Mailing Address - Fax:
Practice Address - Street 1:1700 AUTUMNWOOD BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-1704
Practice Address - Country:US
Practice Address - Phone:931-436-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker