Healthcare Provider Details

I. General information

NPI: 1972286862
Provider Name (Legal Business Name): MOSAIC PATHWAY COUNSELING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NATIONS DR STE 111
GURNEE IL
60031-9170
US

IV. Provider business mailing address

1800 NATIONS DR STE 111
GURNEE IL
60031-9170
US

V. Phone/Fax

Practice location:
  • Phone: 847-710-0612
  • Fax:
Mailing address:
  • Phone: 847-710-0612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT E STOLARICK
Title or Position: OWNER
Credential: LCPC, CCTP
Phone: 847-710-0612