Provider Demographics
NPI:1225800774
Name:MOHAMED, MUSTAFA S
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:S
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 1:5775 WAYZATA BLVD STE 700
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1233
Mailing Address - Country:US
Mailing Address - Phone:651-307-3934
Mailing Address - Fax:
Practice Address - Street 1:5775 WAYZATA BLVD STE 700
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1233
Practice Address - Country:US
Practice Address - Phone:651-307-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent