Provider Demographics
NPI:1134862840
Name:ALI, FADUMO
Entity type:Individual
Prefix:
First Name:FADUMO
Middle Name:
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 1:2424 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3808
Mailing Address - Country:US
Mailing Address - Phone:763-742-9250
Mailing Address - Fax:
Practice Address - Street 1:2118 BLAISDELL AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2415
Practice Address - Country:US
Practice Address - Phone:763-742-9250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306343101YA0400X
MN4450101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)