Provider Demographics
NPI:1790376705
Name:ABDILAHI, KHADRA MOHAMED
Entity Type:Individual
Prefix:
First Name:KHADRA
Middle Name:MOHAMED
Last Name:ABDILAHI
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 1:5901 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5455
Mailing Address - Country:US
Mailing Address - Phone:763-614-6114
Mailing Address - Fax:
Practice Address - Street 1:1925 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2713
Practice Address - Country:US
Practice Address - Phone:612-298-7636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health