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General NPI Number Information
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NPI Number | 1275195737
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Entity Type | Organization
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Legal Business Name | MOSAIC FAMILY SERVICES, LTD.
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Dates
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Enumeration Date | 07/05/2019
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Last Update Date | 07/05/2019
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Provider Practice Location Address
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Address Line | 1405 EAST MAIN STREET
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City | NEW PRAGUE
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State | MN
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Zip | 56071
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Country | US
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Telephone | 952-217-6419
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Fax | 952-758-9022
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Provider Business Mailing Address
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Address Line | 1405 EAST MAIN STREET
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City | NEW PRAGUE
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State | MN
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Zip | 56071
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Country | US
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Telephone | 952-217-6419
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Fax | 952-758-9022
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Authorized Official
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Title or Position | DIRECTOR
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Name | JEREMY ROBISON FAUS
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Credential | LMFT
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Telephone | 952-217-6419
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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