MEDICARE: MRS. SUSAN KAY ALLEN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	630	MT
2	1041C0700X	Clinical Social Worker	630	MT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M011006202	OTHER	MT	MEDICARE PTAN

General Provider Information

NPI Number	:	1215235031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN KAY ALLEN LCSW

Provider Business Mailing Address
First Line	:	PO BOX 353
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59806-0353
Country	:	US
Telephone Number	:	406-303-0397
Fax Number	:	406-721-5912

Provider Business Practice Location Address
First Line	:	415 N HIGGINS
Second Line	:	SUITE 4
City	:	MISSOULA
State	:	MT
Zip	:	59802-4559
Country	:	US
Telephone Number	:	406-303-0397
Fax Number	:	406-721-5912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2011
Last Update Date	:	07/29/2015

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