=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730798224
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SATTVA YOGA THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2020
-----------------------------------------------------
Last Update Date | 07/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1027 W RUDISILL BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46807-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-450-3751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1027 W RUDISILL BLVD
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46807-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-450-3751
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | YOGA THERAPIST
-----------------------------------------------------
Name | DANIELLE MARIE MCGUIRE
-----------------------------------------------------
Credential | C-IAYT
-----------------------------------------------------
Telephone | 260-450-3751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------