Provider Demographics
NPI:1003508193
Name:MAHAD, NIMCO
Entity Type:Individual
Prefix:
First Name:NIMCO
Middle Name:
Last Name:MAHAD
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 1:8632 SARATOGA LN
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-1613
Mailing Address - Country:US
Mailing Address - Phone:952-393-2189
Mailing Address - Fax:
Practice Address - Street 1:11972 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-1516
Practice Address - Country:US
Practice Address - Phone:952-228-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician