Provider Demographics
NPI:1881467116
Name:SANNOH, MORIBA
Entity type:Individual
Prefix:
First Name:MORIBA
Middle Name:
Last Name:SANNOH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2669 SCOTLAND COURT
Mailing Address - Street 2:309
Mailing Address - City:MOUNDS VIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55112
Mailing Address - Country:US
Mailing Address - Phone:801-916-9813
Mailing Address - Fax:
Practice Address - Street 1:1627 WHITE BEAR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-1609
Practice Address - Country:US
Practice Address - Phone:651-278-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician