Provider Demographics
NPI:1518208008
Name:MOSAIC CENTER FOR INTEGRATIVE THERAPY, LLC
Entity Type:Organization
Organization Name:MOSAIC CENTER FOR INTEGRATIVE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSNIESS OWNER / THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-1750
Mailing Address - Street 1:2202 MITCHELL PARK DR
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8897
Mailing Address - Country:US
Mailing Address - Phone:231-487-1750
Mailing Address - Fax:231-487-1754
Practice Address - Street 1:2202 MITCHELL PARK DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8897
Practice Address - Country:US
Practice Address - Phone:231-487-1750
Practice Address - Fax:231-487-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-07
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085534251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1386972446OtherTYPE I NPI