Healthcare Provider Details

I. General information

NPI: 1194634634
Provider Name (Legal Business Name): DAVID MOBLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W LAKE ST STE 104
CHICAGO IL
60606-1945
US

IV. Provider business mailing address

201 W LAKE ST STE 104
CHICAGO IL
60606-1945
US

V. Phone/Fax

Practice location:
  • Phone: 470-582-8092
  • Fax: 470-582-8092
Mailing address:
  • Phone: 470-582-8092
  • Fax: 470-582-8092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number150118122
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: