MEDICARE: MOBILE MENTALHEALTH 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	01524843	NV

General Provider Information

NPI Number	:	1215221866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE MENTALHEALTH SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	406 S 11TH ST
Second Line	:	APT 9
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-7128
Country	:	US
Telephone Number	:	818-641-9856
Fax Number	:

Provider Business Practice Location Address
First Line	:	406 S 11TH ST
Second Line	:	APT 9
City	:	LAS VEGAS
State	:	NV
Zip	:	89101-7128
Country	:	US
Telephone Number	:	818-641-9856
Fax Number	:

Authorized Official
Title or Position	:	QBA
Name	:	MRS. MILAGROS JAMITO PRIANES
Credential	:	DIPLOMA
Telephone Number	:	818-641-9856

Provider Enumeration Date	:	05/31/2011
Last Update Date	:	05/31/2011

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