Provider Demographics
NPI:1285196659
Name:OMAR, SHAMSO
Entity Type:Individual
Prefix:
First Name:SHAMSO
Middle Name:
Last Name:OMAR
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 1:3355 HIAWATHA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2441
Mailing Address - Country:US
Mailing Address - Phone:612-886-2618
Mailing Address - Fax:612-808-8598
Practice Address - Street 1:3355 HIAWATHA AVE STE 100
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2441
Practice Address - Country:US
Practice Address - Phone:612-886-2618
Practice Address - Fax:612-808-8598
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician