Provider Demographics
NPI:1568933406
Name:MOUSA, ESRAA M
Entity Type:Individual
Prefix:MRS
First Name:ESRAA
Middle Name:M
Last Name:MOUSA
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:PO BOX 804
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121-0804
Mailing Address - Country:US
Mailing Address - Phone:313-715-7152
Mailing Address - Fax:313-581-1144
Practice Address - Street 1:6558 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1701
Practice Address - Country:US
Practice Address - Phone:313-581-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI832720547OtherAUTO