Provider Demographics
NPI:1093272494
Name:KASSOUF, ADAM (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:KASSOUF
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 MARGARET CT
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9507
Mailing Address - Country:US
Mailing Address - Phone:336-575-8515
Mailing Address - Fax:
Practice Address - Street 1:508 WILLIAMSON RD STE 200
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9186
Practice Address - Country:US
Practice Address - Phone:704-360-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist