Provider Demographics
NPI:1083482012
Name:DAHIR, FARDOWSA
Entity Type:Individual
Prefix:
First Name:FARDOWSA
Middle Name:
Last Name:DAHIR
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 1:9301 RIVER ROCK DR N
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4746
Mailing Address - Country:US
Mailing Address - Phone:952-261-6896
Mailing Address - Fax:
Practice Address - Street 1:9301 RIVER ROCK DR N
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-4746
Practice Address - Country:US
Practice Address - Phone:952-261-6896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-19
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171M00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator