MEDICARE: MOBILE MENTAL HEALTH SUPPORT SERVICES, INC.

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1720376510
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE MENTAL HEALTH SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	3085 S JONES BLVD STE C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6767
Country	:	US
Telephone Number	:	702-888-0036
Fax Number	:	702-888-0035

Provider Business Practice Location Address
First Line	:	3085 S JONES BLVD STE C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6767
Country	:	US
Telephone Number	:	702-888-0036
Fax Number	:	702-888-0035

Authorized Official
Title or Position	:	CEO
Name	:	TANITSHA BRIDGERS
Credential	:	LCSW
Telephone Number	:	702-556-1511

Provider Enumeration Date	:	07/14/2011
Last Update Date	:	07/14/2011

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