Provider Demographics
NPI:1497307045
Name:MOBILE MENTAL WELLNESS, LLC
Entity Type:Organization
Organization Name:MOBILE MENTAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:866-413-1988
Mailing Address - Street 1:10208 S INDIANAPOLIS AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-6033
Mailing Address - Country:US
Mailing Address - Phone:866-413-1988
Mailing Address - Fax:866-628-8599
Practice Address - Street 1:10208 S INDIANAPOLIS AVE STE 301
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-6033
Practice Address - Country:US
Practice Address - Phone:866-413-1988
Practice Address - Fax:866-628-8599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-14
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361685801001Medicaid
IN300007929Medicaid