Provider Demographics
NPI:1770011058
Name:MOSAIC PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:MOSAIC PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MULLEN
Authorized Official - Last Name:MAGBALON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:229-233-8009
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-0378
Mailing Address - Country:US
Mailing Address - Phone:229-233-8009
Mailing Address - Fax:229-233-8037
Practice Address - Street 1:229 REMINGTON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5522
Practice Address - Country:US
Practice Address - Phone:229-233-8009
Practice Address - Fax:229-233-8037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003712103T00000X
GALCSW0045231041C0700X
GALMFT001440106H00000X
GAPSY003406103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty