MEDICARE: MS. PARISS BOBO-MITCHELL

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	320800000X	Mental Illness Community Based Residential Treatment Facility
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1528849916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PARISS BOBO-MITCHELL

Provider Business Mailing Address
First Line	:	11201 N TATUM BLVD STE 300
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-6039
Country	:	US
Telephone Number	:	602-743-5845
Fax Number	:

Provider Business Practice Location Address
First Line	:	7121 W WILLIAMS ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-7809
Country	:	US
Telephone Number	:	602-743-5845
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2023
Last Update Date	:	10/11/2023

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