Provider Demographics
NPI:1386663573
Name:WAKEFIELD, AIDA BADRAN
Entity Type:Individual
Prefix:MRS
First Name:AIDA
Middle Name:BADRAN
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AIDA
Other - Middle Name:MARIE
Other - Last Name:BADRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:600 DEMERS AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4599
Mailing Address - Country:US
Mailing Address - Phone:701-746-9341
Mailing Address - Fax:701-746-1136
Practice Address - Street 1:600 DEMERS AVE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4599
Practice Address - Country:US
Practice Address - Phone:701-746-9341
Practice Address - Fax:701-746-1136
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
A006OtherWPS
MN5G324WAOtherBCBS MN
MN5G324WAOtherBLUEPLUSMN MEDICAID
6257044OtherUBH
NDBAD24778OtherBCBS ND
ND19143Medicaid
NDBAD24778OtherBCBS ND