Provider Demographics
NPI:1942032776
Name:MOSAIC VILLAGE
Entity type:Organization
Organization Name:MOSAIC VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:435-619-3028
Mailing Address - Street 1:PO BOX 3184
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86021-3184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:580 E WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:HILDALE
Practice Address - State:UT
Practice Address - Zip Code:84784-7761
Practice Address - Country:US
Practice Address - Phone:435-619-3028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty