Healthcare Provider Details

I. General information

NPI: 1073388047
Provider Name (Legal Business Name): MOSAIC HEALING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 CARLISLE BLVD NE STE A
ALBUQUERQUE NM
87110-4971
US

IV. Provider business mailing address

4804 OVERLAND ST NE
ALBUQUERQUE NM
87109-2667
US

V. Phone/Fax

Practice location:
  • Phone: 505-720-3781
  • Fax:
Mailing address:
  • Phone: 505-720-3781
  • 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: JULIE K GRAY
Title or Position: OWNER
Credential: LCSW
Phone: 505-720-3781