Provider Demographics
NPI:1417003815
Name:MOSAIC PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:MOSAIC PSYCHOLOGICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT TUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:914-764-4413
Mailing Address - Street 1:23 OLD SNAKE HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:POUND RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10576-2101
Mailing Address - Country:US
Mailing Address - Phone:914-764-4413
Mailing Address - Fax:
Practice Address - Street 1:23 OLD SNAKE HILL ROAD
Practice Address - Street 2:
Practice Address - City:POUND RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10576-2101
Practice Address - Country:US
Practice Address - Phone:914-764-4413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01727471Medicaid
NY01727471Medicaid