Healthcare Provider Details

I. General information

NPI: 1538477583
Provider Name (Legal Business Name): MOKSHA LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 17TH ST NW SUITE 1000
WASHINGTON DC
20036-5503
US

IV. Provider business mailing address

1050 17TH ST NW SUITE 1000
WASHINGTON DC
20036-5503
US

V. Phone/Fax

Practice location:
  • Phone: 202-508-3796
  • Fax: 202-758-2742
Mailing address:
  • Phone: 202-508-3796
  • Fax: 202-758-2742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS50078247
License Number StateDC

VIII. Authorized Official

Name: MR. ED WILSON
Title or Position: BILLING MANAGER
Credential:
Phone: 956-369-8628