MEDICARE: MATT ALLEN CPSS

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	174400000X	Specialist		KY
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	288501	KY

General Provider Information

NPI Number	:	1639854946
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATT ALLEN CPSS

Provider Business Mailing Address
First Line	:	159 WATERWORKS RD
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-8225
Country	:	US
Telephone Number	:	606-224-7488
Fax Number	:

Provider Business Practice Location Address
First Line	:	565 HIGHWAY 192 W
Second Line	:
City	:	LONDON
State	:	KY
Zip	:	40741-2637
Country	:	US
Telephone Number	:	606-224-7488
Fax Number	:

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

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	02/05/2025

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