Provider Demographics
NPI:1023691193
Name:FARAH, KHADAR
Entity type:Individual
Prefix:
First Name:KHADAR
Middle Name:
Last Name:FARAH
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 1:1821 UNIVERSITY AVE W STE 279
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-2801
Mailing Address - Country:US
Mailing Address - Phone:612-552-8486
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W STE 279
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2801
Practice Address - Country:US
Practice Address - Phone:612-552-8486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MN3237101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician