=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528760071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED JOURNEY INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2023
-----------------------------------------------------
Last Update Date | 03/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20550 S LAGRANGE RD STE 210
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-6042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-703-1791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11501 KLUTH DR
-----------------------------------------------------
City | MOKENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60448-9405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-703-1791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANA MASSAT
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 708-703-1791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------