Healthcare Provider Details

I. General information

NPI: 1942032776
Provider Name (Legal Business Name): MOSAIC VILLAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 E WILLIAMS AVE
HILDALE UT
84784-7761
US

IV. Provider business mailing address

PO BOX 3184
COLORADO CITY AZ
86021-3184
US

V. Phone/Fax

Practice location:
  • Phone: 435-619-3028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER MIDDLETON
Title or Position: OWNER
Credential: BCBA, LBA
Phone: 435-619-3028