Provider Demographics
NPI:1669572426
Name:MOSES, IVETTE SUSAN (PT)
Entity type:Individual
Prefix:MRS
First Name:IVETTE
Middle Name:SUSAN
Last Name:MOSES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MISS
Other - First Name:IVETTE
Other - Middle Name:SUSAN
Other - Last Name:FIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 SANDPOINTE AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-5778
Mailing Address - Country:US
Mailing Address - Phone:714-557-9292
Mailing Address - Fax:714-557-9137
Practice Address - Street 1:201 SANDPOINTE AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-5778
Practice Address - Country:US
Practice Address - Phone:714-557-9292
Practice Address - Fax:714-557-9137
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 19565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 19565OtherPT LICENSE
CAWPT19565AMedicare ID - Type UnspecifiedPPIN