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General NPI Number Information
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NPI Number | 1639541428
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Entity Type | Organization
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Legal Business Name | MOSAIC COUNSELING AND CONSULTING LLC
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Dates
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Enumeration Date | 10/20/2015
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Last Update Date | 10/20/2015
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Provider Practice Location Address
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Address Line | 1401 S WALDRON RD SUITE 200
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City | FORT SMITH
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State | AR
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Zip | 72903-2591
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Country | US
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Telephone | 479-263-7567
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Fax | 479-452-2958
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Provider Business Mailing Address
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Address Line | PO BOX 10124
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-0037
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. RYAN A MARTIN
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Credential | PHD, LPC-S
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Telephone | 479-263-7567
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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 | P0610054
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License Number State | AR
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