Healthcare Provider Details

I. General information

NPI: 1215709019
Provider Name (Legal Business Name): MOKSHA LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 E GRAFTON RD STE A
FAIRMONT WV
26554-4465
US

IV. Provider business mailing address

14 E GRAFTON RD STE A
FAIRMONT WV
26554-4465
US

V. Phone/Fax

Practice location:
  • Phone: 681-214-0025
  • Fax:
Mailing address:
  • Phone: 681-214-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DARICE RENEE YERKOVICH
Title or Position: OWNER
Credential: LICSW
Phone: 681-214-0025