Provider Demographics
NPI:1740604719
Name:SOUTHWEST MOBILE MBS, LLC
Entity Type:Organization
Organization Name:SOUTHWEST MOBILE MBS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:480-375-0145
Mailing Address - Street 1:712 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-1194
Mailing Address - Country:US
Mailing Address - Phone:480-375-0145
Mailing Address - Fax:602-535-4702
Practice Address - Street 1:712 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-1194
Practice Address - Country:US
Practice Address - Phone:480-375-0145
Practice Address - Fax:602-535-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5512235Z00000X
AZ261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MobileGroup - Single Specialty