Provider Demographics
NPI:1174002356
Name:MOSAIC LEAF THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:MOSAIC LEAF THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST AND FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LABARRIE MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-522-8280
Mailing Address - Street 1:200 W MADISON ST STE 2100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3521
Mailing Address - Country:US
Mailing Address - Phone:312-522-8280
Mailing Address - Fax:
Practice Address - Street 1:200 W MADISON ST STE 2100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606
Practice Address - Country:US
Practice Address - Phone:312-522-8280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009800261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health