Provider Demographics
NPI:1205570843
Name:MOSAIC COUNSELING SERVICES, INC
Entity type:Organization
Organization Name:MOSAIC COUNSELING SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:815-846-0684
Mailing Address - Street 1:6072 BRYNWOOD DR STE 107
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-5829
Mailing Address - Country:US
Mailing Address - Phone:815-846-0684
Mailing Address - Fax:888-827-2114
Practice Address - Street 1:6072 BRYNWOOD DR STE 107
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5829
Practice Address - Country:US
Practice Address - Phone:815-846-0684
Practice Address - Fax:888-827-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-20
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1003319781OtherNPI TYPE 1