Provider Demographics
NPI:1467993956
Name:MOHAMED, KASSIM
Entity Type:Individual
Prefix:
First Name:KASSIM
Middle Name:
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 1:860 BLUE GENTIAN RD
Mailing Address - Street 2:STE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1564
Mailing Address - Country:US
Mailing Address - Phone:952-737-2965
Mailing Address - Fax:
Practice Address - Street 1:860 BLUE GENTIAN RD
Practice Address - Street 2:STE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55121-1564
Practice Address - Country:US
Practice Address - Phone:952-737-2965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1084488106S00000X, 172A00000X, 374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172A00000XOther Service ProvidersDriver