Provider Demographics
NPI:1205688371
Name:IBRAHIM, FAIZA S
Entity type:Individual
Prefix:
First Name:FAIZA
Middle Name:S
Last Name:IBRAHIM
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 1:14125 VIRGINIA AVE S STE 214
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2663
Mailing Address - Country:US
Mailing Address - Phone:952-217-6255
Mailing Address - Fax:
Practice Address - Street 1:14125 VIRGINIA AVE S STE 214
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2663
Practice Address - Country:US
Practice Address - Phone:952-217-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNG977-096-068-823103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty