MEDICARE: DARRYL VINCENT ALLEN M.A.

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	101YA0400X	Addiction (Substance Use Disorder)	C-00372	MI
2	101YP2500X	Professional	6401008657	MI

General Provider Information

NPI Number	:	1659548212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARRYL VINCENT ALLEN M.A.

Provider Business Mailing Address
First Line	:	14923 FAUST AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-2303
Country	:	US
Telephone Number	:	313-456-6036
Fax Number	:

Provider Business Practice Location Address
First Line	:	7430 2ND AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-2739
Country	:	US
Telephone Number	:	313-456-6036
Fax Number	:

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

Provider Enumeration Date	:	05/13/2008
Last Update Date	:	05/13/2008

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