Provider Demographics
NPI:1649863648
Name:MOSAIC - MUMBY PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:MOSAIC - MUMBY PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUMBY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MSW
Authorized Official - Phone:602-902-6696
Mailing Address - Street 1:11773 S 53RD DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-5432
Mailing Address - Country:US
Mailing Address - Phone:602-902-6696
Mailing Address - Fax:
Practice Address - Street 1:11773 S 53RD DR
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-5432
Practice Address - Country:US
Practice Address - Phone:602-902-6696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty