Provider Demographics
NPI:1942667597
Name:MOSAIC HOUSE- CERTS
Entity type:Organization
Organization Name:MOSAIC HOUSE- CERTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JARAMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:801-414-0596
Mailing Address - Street 1:1488 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1958
Mailing Address - Country:US
Mailing Address - Phone:801-414-0596
Mailing Address - Fax:801-268-9303
Practice Address - Street 1:1488 E VINE ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84121-1958
Practice Address - Country:US
Practice Address - Phone:801-414-0596
Practice Address - Fax:801-268-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0015901320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness