Provider Demographics
NPI:1548785835
Name:MOUA, MANG
Entity Type:Individual
Prefix:MRS
First Name:MANG
Middle Name:
Last Name:MOUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1481 N PEACH AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-2078
Mailing Address - Country:US
Mailing Address - Phone:559-519-8025
Mailing Address - Fax:
Practice Address - Street 1:7005 N MAPLE AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8009
Practice Address - Country:US
Practice Address - Phone:559-325-3503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3789224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant