Healthcare Provider Details

I. General information

NPI: 1538071774
Provider Name (Legal Business Name): ANDRE HENRIQUE PROSISE MOURA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5579 S ORANGE AVE
EDGEWOOD FL
32809-3493
US

IV. Provider business mailing address

16480 WINDSOR CAY BLVD APT 301
CLERMONT FL
34714-7336
US

V. Phone/Fax

Practice location:
  • Phone: 407-241-4800
  • Fax:
Mailing address:
  • Phone: 689-323-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT45358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: