Provider Demographics
NPI:1376749762
Name:MOUSSAS, ELIZABETH DIANE (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DIANE
Last Name:MOUSSAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 SENTRY DR
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41076-1465
Mailing Address - Country:US
Mailing Address - Phone:859-442-7338
Mailing Address - Fax:
Practice Address - Street 1:69 SENTRY DR
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41076-1465
Practice Address - Country:US
Practice Address - Phone:859-442-7338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3942103T00000X, 103TC0700X, 103TH0004X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0687225Medicaid