Provider Demographics
NPI:1669724357
Name:MOBILE PSYCHOLOGY, LLC
Entity type:Organization
Organization Name:MOBILE PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RITA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JUNGBLOM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:270-875-2544
Mailing Address - Street 1:345 LEROY ROAD
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:KY
Mailing Address - Zip Code:42413-9657
Mailing Address - Country:US
Mailing Address - Phone:270-875-2544
Mailing Address - Fax:270-342-5411
Practice Address - Street 1:345 LEROY ROAD
Practice Address - Street 2:
Practice Address - City:HANSON
Practice Address - State:KY
Practice Address - Zip Code:42413-9657
Practice Address - Country:US
Practice Address - Phone:270-875-2544
Practice Address - Fax:270-342-5411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1355103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100240540Medicaid
KY7100297310Medicaid