Provider Demographics
NPI:1750309498
Name:MOUSSA, HENRY S (RPT)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:S
Last Name:MOUSSA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 LAKES DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2924
Mailing Address - Country:US
Mailing Address - Phone:626-918-6655
Mailing Address - Fax:
Practice Address - Street 1:1050 LAKES DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2924
Practice Address - Country:US
Practice Address - Phone:626-918-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA253152251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT25315AMedicare ID - Type Unspecified