Provider Demographics
NPI:1104126077
Name:MOUA, PAO L
Entity type:Individual
Prefix:MR
First Name:PAO
Middle Name:L
Last Name:MOUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12310 MONTAUK WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-7724
Mailing Address - Country:US
Mailing Address - Phone:916-833-5471
Mailing Address - Fax:
Practice Address - Street 1:500 JEFFERSON BLVD
Practice Address - Street 2:BLDG. B, SUITE 150
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2350
Practice Address - Country:US
Practice Address - Phone:916-376-8591
Practice Address - Fax:916-376-8595
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health