Provider Demographics
NPI:1215212972
Name:MOSAIC THERAPY INC
Entity Type:Organization
Organization Name:MOSAIC THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VYAZOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:312-799-9351
Mailing Address - Street 1:4700 OLD ORCHARD RD
Mailing Address - Street 2:APT 211
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 OLD ORCHARD RD
Practice Address - Street 2:APT 211
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1061
Practice Address - Country:US
Practice Address - Phone:312-799-9351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007758101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty