=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487549010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOSAIC MIND PSYCHOTHERAPY LCSW PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2025
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 MAPLE AVE STE 106
-----------------------------------------------------
City | BAY SHORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11706-8752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-532-9268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 MAPLE AVE STE 106
-----------------------------------------------------
City | BAY SHORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11706-8752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-532-9268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. MEGHAN MCLEOD
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 631-532-9268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------