Healthcare Provider Details

I. General information

NPI: 1497307045
Provider Name (Legal Business Name): MOBILE MENTAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2019
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CUMBERLAND XING # 108
VALPARAISO IN
46383-2356
US

IV. Provider business mailing address

980 N MICHIGAN AVE STE 1090 PMB 344989
CHICAGO IL
60611-4521
US

V. Phone/Fax

Practice location:
  • Phone: 866-413-1988
  • Fax: 866-628-8599
Mailing address:
  • Phone: 866-413-1988
  • Fax: 866-628-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY TRAVIS
Title or Position: OWNER
Credential: LCSW
Phone: 866-413-1988