Provider Demographics
NPI:1528849916
Name:BOBO-MITCHELL, PARISS
Entity type:Individual
Prefix:MS
First Name:PARISS
Middle Name:
Last Name:BOBO-MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:TIMECIA
Other - Middle Name:
Other - Last Name:INGRAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11201 N TATUM BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6039
Mailing Address - Country:US
Mailing Address - Phone:602-743-5845
Mailing Address - Fax:
Practice Address - Street 1:7121 W WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-7809
Practice Address - Country:US
Practice Address - Phone:602-743-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness