Provider Demographics
NPI:1871148171
Name:ALLEN, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E MENEFEE ST
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-4701
Mailing Address - Country:US
Mailing Address - Phone:936-676-6433
Mailing Address - Fax:
Practice Address - Street 1:135 E MENEFEE ST
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-4701
Practice Address - Country:US
Practice Address - Phone:936-676-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251S00000X, 253J00000X
320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency