Provider Demographics
NPI:1467142364
Name:MOHAMED, NADRA SHAFI
Entity Type:Individual
Prefix:
First Name:NADRA
Middle Name:SHAFI
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 1:3401 HIAWATHA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2525
Mailing Address - Country:US
Mailing Address - Phone:612-353-4133
Mailing Address - Fax:612-886-2080
Practice Address - Street 1:3401 HIAWATHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2525
Practice Address - Country:US
Practice Address - Phone:612-353-4133
Practice Address - Fax:612-886-2080
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician