=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023577749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL MOSAIC THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2019
-----------------------------------------------------
Last Update Date | 03/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 S MERAMEC AVE STE 203
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63105-3511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-492-6296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5528 PERSHING AVE APT 405
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63112-1791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-498-4449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. YUIMA MIZUTANI
-----------------------------------------------------
Credential | M.ED., NCC, LPC
-----------------------------------------------------
Telephone | 314-498-4449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------