Healthcare Provider Details

I. General information

NPI: 1174002356
Provider Name (Legal Business Name): MOSAIC LEAF THERAPY AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MADISON ST STE 2100
CHICAGO IL
60606
US

IV. Provider business mailing address

200 W MADISON ST STE 2100
CHICAGO IL
60606-3521
US

V. Phone/Fax

Practice location:
  • Phone: 312-522-8280
  • Fax:
Mailing address:
  • Phone: 312-522-8280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number071.009800
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number071.009800
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number071.009800
License Number StateIL

VIII. Authorized Official

Name: DR. THERESSA L LABARRIE MITCHELL
Title or Position: CLINICAL PSYCHOLOGIST AND FOUNDER
Credential: PHD
Phone: 312-522-8280