Provider Demographics
NPI:1134722507
Name:ALI, FARTUN
Entity type:Individual
Prefix:
First Name:FARTUN
Middle Name:
Last Name:ALI
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 1:14977 LOUISIANA AVE S APT 212
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-4562
Mailing Address - Country:US
Mailing Address - Phone:507-508-8585
Mailing Address - Fax:
Practice Address - Street 1:14977 LOUISIANA AVE S APT 212
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-4562
Practice Address - Country:US
Practice Address - Phone:612-666-0667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician