Provider Demographics
NPI:1841652898
Name:HASSAN, FAIZA
Entity type:Individual
Prefix:
First Name:FAIZA
Middle Name:
Last Name:HASSAN
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 1:10917 HUMBOLDT AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-4221
Mailing Address - Country:US
Mailing Address - Phone:651-315-2649
Mailing Address - Fax:
Practice Address - Street 1:10917 HUMBOLDT AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4221
Practice Address - Country:US
Practice Address - Phone:651-315-2649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0015858320600000X
MN320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities