Basic Information
Provider Information | |||||||||
NPI: | 1154564524 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALLEN | ||||||||
FirstName: | TAMMIE | ||||||||
MiddleName: | LANETT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | BS, MHPP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HALL | ||||||||
OtherFirstName: | TAMMIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MHPP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10025 W MARKHAM ST | ||||||||
Address2: | SUITE 210 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722051407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016635473 | ||||||||
FaxNumber: | 5018011816 | ||||||||
Practice Location | |||||||||
Address1: | 10025 W MARKHAM ST | ||||||||
Address2: | SUITE 210 | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722051407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016635473 | ||||||||
FaxNumber: | 5018011816 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2009 | ||||||||
LastUpdateDate: | 10/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 137548726 | 05 | AR |   | MEDICAID |