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General NPI Number Information
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NPI Number | 1093474652
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Entity Type | Organization
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Legal Business Name | MOVING MOSAIC THERAPY & COUNSELING, PLLC
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Dates
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Enumeration Date | 12/10/2021
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Last Update Date | 10/02/2023
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Provider Practice Location Address
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Address Line | 2232 S 18TH AVE
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City | NORTH RIVERSIDE
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State | IL
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Zip | 60546-1014
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Country | US
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Telephone | 773-373-9682
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Fax | 773-312-4876
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Provider Business Mailing Address
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Address Line | 2232 S 18TH AVE
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City | NORTH RIVERSIDE
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State | IL
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Zip | 60546-1014
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Country | US
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Telephone | 773-373-9682
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Fax | 773-312-4876
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Authorized Official
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Title or Position | CO-FOUNDER/PSYCHOTHERAPIST
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Name | KATIE MARIE DOMINGUEZ
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Credential | MA, LCPC
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Telephone | 773-373-9682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225600000X
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Taxonomy Name | Dance Therapist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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