Provider Demographics
NPI:1497438287
Name:IBRAHIM, MOURA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MOURA
Middle Name:
Last Name:IBRAHIM
Suffix:
Gender:F
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 1:265 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2712
Mailing Address - Country:US
Mailing Address - Phone:197-366-1120
Mailing Address - Fax:
Practice Address - Street 1:310 NEW RD
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-4273
Practice Address - Country:US
Practice Address - Phone:973-396-8667
Practice Address - Fax:973-396-8668
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02196000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist