Provider Demographics
NPI:1790580868
Name:ALI, AJWA OMAR
Entity type:Individual
Prefix:
First Name:AJWA
Middle Name:OMAR
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 1:200 HIGHWAY 13 W STE 140A
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2549
Mailing Address - Country:US
Mailing Address - Phone:612-232-3958
Mailing Address - Fax:612-486-7194
Practice Address - Street 1:200 HIGHWAY 13 W STE 140A
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2549
Practice Address - Country:US
Practice Address - Phone:612-232-3958
Practice Address - Fax:612-486-7194
Is Sole Proprietor?:No
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician