Basic Information
| Provider Information | |||||||||
| NPI: | 1417103649 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOSAIC FAMILY COUNSELING CENTER INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 GRAND AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503122805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157248920 | ||||||||
| FaxNumber: | 8887713225 | ||||||||
| Practice Location | |||||||||
| Address1: | 3705 GRAND AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503122805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157248920 | ||||||||
| FaxNumber: | 8887713225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2008 | ||||||||
| LastUpdateDate: | 08/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | RANDALL | ||||||||
| AuthorizedOfficialFirstName: | KENYA | ||||||||
| AuthorizedOfficialMiddleName: | JOYCE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5157248920 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 001075 | IA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.