Basic Information
| Provider Information | |||||||||
| NPI: | 1528536562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOHAMUD | ||||||||
| FirstName: | FATHI | ||||||||
| MiddleName: | ISSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8200 HUMBOLDT AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554311433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524540421 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8200 HUMBOLDT AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554311433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524540421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2018 | ||||||||
| LastUpdateDate: | 11/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.