Provider Demographics
NPI:1770224701
Name:MOUSSA, JEANINE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:MOUSSA
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 S ALTA VISTA AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4049
Mailing Address - Country:US
Mailing Address - Phone:201-638-5812
Mailing Address - Fax:
Practice Address - Street 1:529 E LIVE OAK AVE STE E
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-5600
Practice Address - Country:US
Practice Address - Phone:626-340-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23340225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics