Provider Demographics
NPI:1114588241
Name:MOSAIC MENTAL WELLNESS
Entity Type:Organization
Organization Name:MOSAIC MENTAL WELLNESS
Other - Org Name:MOSAIC MENTAL WELLNESS AND HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENEEN
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-566-4034
Mailing Address - Street 1:3005 PETERS CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2738
Mailing Address - Country:US
Mailing Address - Phone:540-566-4034
Mailing Address - Fax:540-566-4472
Practice Address - Street 1:3005 PETERS CREEK RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2738
Practice Address - Country:US
Practice Address - Phone:540-520-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-28
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty