Provider Demographics
NPI:1871314583
Name:MOHAMED, MUSHTAQ ALIDAHIR
Entity type:Individual
Prefix:
First Name:MUSHTAQ
Middle Name:ALIDAHIR
Last Name:MOHAMED
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 1:1601 MN 13 N
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-209-5557
Mailing Address - Fax:
Practice Address - Street 1:1601 MN 13 N. SUITE 204
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-209-5557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician