Healthcare Provider Details

I. General information

NPI: 1750686184
Provider Name (Legal Business Name): MOKSA YOGA THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2011
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2265 LIVERNOIS RD STE 260
TROY MI
48083-1639
US

IV. Provider business mailing address

29696 SPOON AVE
MADISON HEIGHTS MI
48071-4437
US

V. Phone/Fax

Practice location:
  • Phone: 985-688-0208
  • Fax: 866-656-1713
Mailing address:
  • Phone: 985-688-0208
  • Fax: 866-656-1713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801083185
License Number StateMI

VIII. Authorized Official

Name: MRS. MARIE ANNETTE FOX
Title or Position: PRESIDENT
Credential: LMSW
Phone: 986-688-0208