Provider Demographics
NPI:1033874763
Name:IBRAHIM, IKRAN
Entity Type:Individual
Prefix:
First Name:IKRAN
Middle Name:
Last Name:IBRAHIM
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 1:3333 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4515
Mailing Address - Country:US
Mailing Address - Phone:612-806-9954
Mailing Address - Fax:306-669-2882
Practice Address - Street 1:3333 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4515
Practice Address - Country:US
Practice Address - Phone:612-806-9954
Practice Address - Fax:306-669-2882
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst