=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538477583
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOKSHA LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2010
-----------------------------------------------------
Last Update Date | 09/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 17TH ST NW SUITE 1000
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-508-3796
-----------------------------------------------------
Fax | 202-758-2742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 17TH ST NW SUITE 1000
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20036-5503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-508-3796
-----------------------------------------------------
Fax | 202-758-2742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MR. ED WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 956-369-8628
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS50078247
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------