Provider Demographics
NPI:1619507340
Name:MOUNGA, MADISON (DPT)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MOUNGA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 W LINCOLN AVE APT 46
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-6499
Mailing Address - Country:US
Mailing Address - Phone:540-903-4783
Mailing Address - Fax:
Practice Address - Street 1:17332 VON KARMAN AVE STE 120
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6282
Practice Address - Country:US
Practice Address - Phone:949-861-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty