Provider Demographics
NPI:1831506211
Name:MOSAIC PSYCHOLOGICAL AND WELLNESS CENTER
Entity type:Organization
Organization Name:MOSAIC PSYCHOLOGICAL AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARRIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KIRKENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:904-806-3070
Mailing Address - Street 1:1201 MACLAREN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3431
Mailing Address - Country:US
Mailing Address - Phone:904-806-3070
Mailing Address - Fax:
Practice Address - Street 1:200 MALAGA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-3523
Practice Address - Country:US
Practice Address - Phone:904-806-3070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty