MEDICARE: MRS. CHARMAIN ILYCE ALLEN RN, LLMSW

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	1041C0700X	Clinical Social Worker	6851117501	MI

General Provider Information

NPI Number	:	1073385308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARMAIN ILYCE ALLEN RN, LLMSW

Provider Business Mailing Address
First Line	:	2134 BEAUFAIT DR
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-1643
Country	:	US
Telephone Number	:	517-214-5199
Fax Number	:

Provider Business Practice Location Address
First Line	:	2134 BEAUFAIT DR
Second Line	:
City	:	GROSSE POINTE WOODS
State	:	MI
Zip	:	48236-1643
Country	:	US
Telephone Number	:	517-214-5199
Fax Number	:

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

Provider Enumeration Date	:	10/30/2023
Last Update Date	:	10/30/2023

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