Provider Demographics
NPI:1497322267
Name:HASSAN, FARDOWSA AHMED (LADC)
Entity Type:Individual
Prefix:
First Name:FARDOWSA
Middle Name:AHMED
Last Name:HASSAN
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5951 UNIVERSITY AVE NE APT 421
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2886
Mailing Address - Country:US
Mailing Address - Phone:612-242-4098
Mailing Address - Fax:
Practice Address - Street 1:1246 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4125
Practice Address - Country:US
Practice Address - Phone:651-204-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305947101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)