MEDICARE: MAXWELL REAS ALLEN

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1780542639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXWELL REAS ALLEN

Provider Business Mailing Address
First Line	:	965 SYRINGA DR
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-4019
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 E 17TH ST STE 355
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-6453
Country	:	US
Telephone Number	:	208-497-0685
Fax Number	:	208-497-0239

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

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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