Provider Demographics
NPI:1912530999
Name:MUSA, IMMAN (PHD)
Entity Type:Individual
Prefix:
First Name:IMMAN
Middle Name:
Last Name:MUSA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 CARROLL SQ APT 1W
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-1515
Mailing Address - Country:US
Mailing Address - Phone:618-363-7325
Mailing Address - Fax:
Practice Address - Street 1:998 N LOMBARD RD
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-1264
Practice Address - Country:US
Practice Address - Phone:630-474-4414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071010223103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical