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General NPI Number Information
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NPI Number | 1942667597
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Entity Type | Organization
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Legal Business Name | MOSAIC HOUSE- CERTS
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Dates
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Enumeration Date | 01/26/2016
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Last Update Date | 01/26/2016
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Provider Practice Location Address
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Address Line | 1488 E VINE ST
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City | MURRAY
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State | UT
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Zip | 84121-1958
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Country | US
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Telephone | 801-414-0596
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Fax | 801-268-9303
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Provider Business Mailing Address
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Address Line | 1488 E VINE ST
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City | MURRAY
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State | UT
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Zip | 84121-1958
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Country | US
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Telephone | 801-414-0596
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Fax | 801-268-9303
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Authorized Official
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Title or Position | DIRECTOR
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Name | LEAH JARAMILLO
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Credential | LMFT
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Telephone | 801-414-0596
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 0015901
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License Number State | UT
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