Healthcare Provider Details

I. General information

NPI: 1124802392
Provider Name (Legal Business Name): MAYA DANNAOUI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 STELLHORN RD
FORT WAYNE IN
46815-4697
US

IV. Provider business mailing address

5651 COVENTRY LN # 112
FORT WAYNE IN
46804-7145
US

V. Phone/Fax

Practice location:
  • Phone: 260-205-8644
  • Fax:
Mailing address:
  • Phone: 260-205-8644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: