MEDICARE: MOBILE MENTAL WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	103TC0700X	Clinical Psychologist
3	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497307045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE MENTAL WELLNESS, LLC

Provider Business Mailing Address
First Line	:	980 N MICHIGAN AVE
Second Line	:	STE 1090 PMB 344989
City	:	CHICAGO
State	:	IL
Zip	:	60611-4521
Country	:	US
Telephone Number	:	866-413-1988
Fax Number	:	866-628-8599

Provider Business Practice Location Address
First Line	:	1101 CUMBERLAND XING # 108
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-2356
Country	:	US
Telephone Number	:	866-413-1988
Fax Number	:	866-628-8599

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY TRAVIS
Credential	:	LCSW
Telephone Number	:	866-413-1988

Provider Enumeration Date	:	07/14/2019
Last Update Date	:	02/02/2026

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