Provider Demographics
NPI:1346823747
Name:THE MOBILE BRAIN, LLC
Entity type:Organization
Organization Name:THE MOBILE BRAIN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE GRACE
Authorized Official - Middle Name:C
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L, CSRS
Authorized Official - Phone:240-839-1390
Mailing Address - Street 1:11140 ROCKVILLE PIKE STE 100-1206
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3106
Mailing Address - Country:US
Mailing Address - Phone:240-839-1454
Mailing Address - Fax:240-399-1354
Practice Address - Street 1:11140 ROCKVILLE PIKE STE 100-1206
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3106
Practice Address - Country:US
Practice Address - Phone:240-839-1454
Practice Address - Fax:240-399-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-03
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD516013800Medicaid