Provider Demographics
NPI:1255509493
Name:MOSAIC COMMUNITY SERVICES
Entity Type:Organization
Organization Name:MOSAIC COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-453-9553
Mailing Address - Street 1:1925 GREENSPRING DR
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4128
Mailing Address - Country:US
Mailing Address - Phone:410-453-9553
Mailing Address - Fax:
Practice Address - Street 1:2225 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5778
Practice Address - Country:US
Practice Address - Phone:410-366-4360
Practice Address - Fax:410-662-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD371331800Medicaid