Provider Demographics
NPI:1942989884
Name:MOHAMED, MOHAMED ALI
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:ALI
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 1:755 SELBY AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-7662
Mailing Address - Country:US
Mailing Address - Phone:612-458-9174
Mailing Address - Fax:
Practice Address - Street 1:4001 STINSON BLVD NE STE 314
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55421-3424
Practice Address - Country:US
Practice Address - Phone:612-345-7306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician