Provider Demographics
NPI:1093449514
Name:MOHAMED, AYAN MAHAMUD
Entity Type:Individual
Prefix:
First Name:AYAN
Middle Name:MAHAMUD
Last Name:MOHAMED
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 1:8227 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1709
Mailing Address - Country:US
Mailing Address - Phone:612-232-9113
Mailing Address - Fax:612-354-3801
Practice Address - Street 1:4001 STINSON BLVD NE STE 314
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3424
Practice Address - Country:US
Practice Address - Phone:612-298-7636
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician