Provider Demographics
NPI:1689321390
Name:OMER, LIAH FAYSAL
Entity Type:Individual
Prefix:
First Name:LIAH
Middle Name:FAYSAL
Last Name:OMER
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 1:10773 PERRY DR N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-4701
Mailing Address - Country:US
Mailing Address - Phone:612-245-9339
Mailing Address - Fax:612-354-3801
Practice Address - Street 1:4001 STINSON BLVD STE 314
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3424
Practice Address - Country:US
Practice Address - Phone:612-298-7636
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician