Provider Demographics
NPI:1134395676
Name:MOURA, ALESSANDRA MACEDO DE
Entity type:Individual
Prefix:MS
First Name:ALESSANDRA
Middle Name:MACEDO DE
Last Name:MOURA
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 1:23077 GREENFIELD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3744
Mailing Address - Country:US
Mailing Address - Phone:248-569-3002
Mailing Address - Fax:248-569-3008
Practice Address - Street 1:23077 GREENFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3744
Practice Address - Country:US
Practice Address - Phone:248-569-3002
Practice Address - Fax:248-569-3008
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650F30621OtherBLUE CROSS/BLUE SHIELD OF MICHIGAN
MIP40780005Medicare PIN