Healthcare Provider Details

I. General information

NPI: 1568933406
Provider Name (Legal Business Name): MRS. ESRAA M MOUSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6558 GREENFIELD RD
DEARBORN MI
48126-1701
US

IV. Provider business mailing address

PO BOX 804
DEARBORN MI
48121-0804
US

V. Phone/Fax

Practice location:
  • Phone: 313-581-1155
  • Fax:
Mailing address:
  • Phone: 313-715-7152
  • Fax: 313-581-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: