Healthcare Provider Details

I. General information

NPI: 1720872450
Provider Name (Legal Business Name): ANTHONY M ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 HARBOUR VIEW BLVD
SUFFOLK VA
23435-2761
US

IV. Provider business mailing address

4011 RAVINE GAP DR
SUFFOLK VA
23434-3051
US

V. Phone/Fax

Practice location:
  • Phone: 757-758-5106
  • Fax:
Mailing address:
  • Phone: 757-235-3859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704015305
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: