Provider Demographics
NPI:1023577749
Name:INTERNATIONAL MOSAIC THERAPY
Entity Type:Organization
Organization Name:INTERNATIONAL MOSAIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:YUIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZUTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MED, NCC, LPC
Authorized Official - Phone:314-498-4449
Mailing Address - Street 1:5528 PERSHING AVE APT 405
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-1791
Mailing Address - Country:US
Mailing Address - Phone:314-498-4449
Mailing Address - Fax:
Practice Address - Street 1:225 S MERAMEC AVE STE 203
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3511
Practice Address - Country:US
Practice Address - Phone:314-492-6296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1841771748Medicaid