Healthcare Provider Details

I. General information

NPI: 1174343511
Provider Name (Legal Business Name): MINDFUL MOSAIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 HAMPTON POINT DR STE 1
ST AUGUSTINE FL
32092-3054
US

IV. Provider business mailing address

246 CASA SEVILLA AVE
ST AUGUSTINE FL
32092-4720
US

V. Phone/Fax

Practice location:
  • Phone: 850-629-8242
  • Fax:
Mailing address:
  • Phone: 850-629-8242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER AREVALO
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 850-629-8242