Provider Demographics
NPI:1073200903
Name:MOHAMED, MOWAFAG
Entity Type:Individual
Prefix:
First Name:MOWAFAG
Middle Name:
Last Name:MOHAMED
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 1:8416 XERXES AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55444-1469
Mailing Address - Country:US
Mailing Address - Phone:651-493-5102
Mailing Address - Fax:651-666-1236
Practice Address - Street 1:8416 XERXES AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-1469
Practice Address - Country:US
Practice Address - Phone:651-493-5102
Practice Address - Fax:651-666-1236
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst