Healthcare Provider Details

I. General information

NPI: 1134279284
Provider Name (Legal Business Name): MOSAIC COMMUNITY SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 GREENSPRING DR
TIMONIUM MD
21093-4113
US

IV. Provider business mailing address

1925 GREENSPRING DR
TIMONIUM MD
21093-4128
US

V. Phone/Fax

Practice location:
  • Phone: 410-453-9550
  • Fax: 410-308-8926
Mailing address:
  • Phone: 410-453-9553
  • Fax: 410-308-8926

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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF RICHARDSON
Title or Position: CEO
Credential: LCSW-C
Phone: 410-453-9553