MEDICARE: MOBILE MENTAL HEALTH 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	320700000X	Physical Disabilities Residential Treatment Facility		NV

General Provider Information

NPI Number	:	1871734772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE MENTAL HEALTH SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	5348 HANGING TREE LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-2032
Country	:	US
Telephone Number	:	702-556-1511
Fax Number	:

Provider Business Practice Location Address
First Line	:	5348 HANGING TREE LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-2032
Country	:	US
Telephone Number	:	702-556-1511
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL ADMINISTRATOR
Name	:	TANITSHA K. BRIDGERS
Credential	:	MSW
Telephone Number	:	702-556-1511

Provider Enumeration Date	:	03/23/2009
Last Update Date	:	03/23/2009

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