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Organization
MOVING MOSAIC THERAPY & COUNSELING, PLLC
Active
Organization
MOVING MOSAIC THERAPY & COUNSELING, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KATIE MARIE DOMINGUEZ MA, LCPC (CO-FOUNDER/PSYCHOTHERAPIST)
(773) 373-9682
Entity
Organization
Contact information
Practice address
2232 S 18TH AVE, NORTH RIVERSIDE, IL 60546-1014
(773) 373-9682
(773) 312-4876
Mailing address
2232 S 18TH AVE, NORTH RIVERSIDE, IL 60546-1014
(773) 373-9682
(773) 312-4876
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
101YM0800X
Mental Health Counselor
—
—
101YP2500X
Professional Counselor
Primary
—
—
225600000X
Dance Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1407515919
NPI
IL
01
—
1447804869
NPPES
IL
01
—
1518427731
NPI
IL
01
—
6839423
AETNA PPO OUTPATIENT PROVIDER
IL
Enumeration date
12/10/2021
Last updated
10/02/2023
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