MEDICARE: MOZAIC THERAPEUTIC SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12471861	OTHER	AZ	CAQH
2	14539	OTHER	AZ	AZLPC

General Provider Information

NPI Number	:	1164980678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOZAIC THERAPEUTIC SERVICES

Provider Business Mailing Address
First Line	:	6700 N ORACLE RD STE 411
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-7734
Country	:	US
Telephone Number	:	520-891-2127
Fax Number	:	520-334-1428

Provider Business Practice Location Address
First Line	:	6700 N ORACLE RD STE 411
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-7734
Country	:	US
Telephone Number	:	520-891-2127
Fax Number	:	520-334-1428

Authorized Official
Title or Position	:	ADMIN
Name	:	ADELLA CORDOVA
Credential	:
Telephone Number	:	623-326-1055

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	03/05/2019

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Directions to “MOZAIC THERAPEUTIC SERVICES ” Practice Location

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