Basic Information
| Provider Information | |||||||||
| NPI: | 1922530690 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | ELENA | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 781625 PO BOX 78000 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 BUTTERFLY GARDENS DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432153427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2017 | ||||||||
| LastUpdateDate: | 01/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.2002491 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | S.1501139 | OH | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |