Healthcare Provider Details

I. General information

NPI: 1528523925
Provider Name (Legal Business Name): MOHAMED MOUSSA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2019
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 MASON ST # A240
DEARBORN MI
48124-2231
US

IV. Provider business mailing address

835 MASON ST # A240
DEARBORN MI
48124-2231
US

V. Phone/Fax

Practice location:
  • Phone: 313-310-7755
  • Fax:
Mailing address:
  • Phone: 313-310-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704389336
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: