MEDICARE: MRS. CHANELL MJ ALLEN QMHP

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	225400000X	Rehabilitation Practitioner	21-QMHA-R1929	OR
2	101Y00000X	Counselor	23-QMHA-I-004113

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23-QMHA-I-004113	OTHER		MHACBO

General Provider Information

NPI Number	:	1558098962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHANELL MJ ALLEN QMHP

Provider Business Mailing Address
First Line	:	4780 W ANN RD STE 375
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-3470
Country	:	US
Telephone Number	:	702-550-9323
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 N TENAYA WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-0420
Country	:	US
Telephone Number	:	702-379-5927
Fax Number	:

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

Provider Enumeration Date	:	08/05/2022
Last Update Date	:	02/07/2024

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