Provider Demographics
NPI:1588237804
Name:MOUSER, PAMELA SUE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:MOUSER
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 1:250 COUNTY ROAD 744
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-6288
Mailing Address - Country:US
Mailing Address - Phone:334-494-6035
Mailing Address - Fax:
Practice Address - Street 1:4800 RUCKER BLVD
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-8763
Practice Address - Country:US
Practice Address - Phone:334-464-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-19-85306106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL133086Medicaid