Provider Demographics
NPI:1720686660
Name:MAHAMOUD, RODA
Entity Type:Individual
Prefix:
First Name:RODA
Middle Name:
Last Name:MAHAMOUD
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 1:12790 PRIMROSE LN APT 103
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7632
Mailing Address - Country:US
Mailing Address - Phone:952-210-2674
Mailing Address - Fax:
Practice Address - Street 1:12790 PRIMROSE LN APT 103
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7632
Practice Address - Country:US
Practice Address - Phone:952-210-2674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician