Provider Demographics
NPI:1558126540
Name:MOUAWIA, MUSTAPHA
Entity Type:Individual
Prefix:DR
First Name:MUSTAPHA
Middle Name:
Last Name:MOUAWIA
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:MUSTAPHA
Other - Middle Name:
Other - Last Name:MOUAWIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4794 ROSALIE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2829
Mailing Address - Country:US
Mailing Address - Phone:313-423-5878
Mailing Address - Fax:
Practice Address - Street 1:4794 ROSALIE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2829
Practice Address - Country:US
Practice Address - Phone:313-423-5878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009851103TB0200X
MI6351004683103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral