Provider Demographics
NPI:1558098962
Name:ALLEN, CHANELL MJ (QMHP)
Entity Type:Individual
Prefix:MRS
First Name:CHANELL
Middle Name:MJ
Last Name:ALLEN
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4780 W ANN RD STE 375
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3470
Mailing Address - Country:US
Mailing Address - Phone:702-550-9323
Mailing Address - Fax:
Practice Address - Street 1:2400 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0420
Practice Address - Country:US
Practice Address - Phone:702-379-5927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-QMHA-R1929225400000X
23-QMHA-I-004113101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
23-QMHA-I-004113OtherMHACBO