Healthcare Provider Details

I. General information

NPI: 1851065502
Provider Name (Legal Business Name): MOSAIC COUNSELING AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 06/23/2023
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAKE ST
OAK PARK IL
60301-1147
US

IV. Provider business mailing address

386 N. YORK RD SUITE 204
ELMHURST IL
60126-2365
US

V. Phone/Fax

Practice location:
  • Phone: 708-628-8000
  • Fax:
Mailing address:
  • Phone: 708-628-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAREY CARLOCK
Title or Position: MANAGER
Credential: MA
Phone: 708-628-8000