Basic Information
| Provider Information | |||||||||
| NPI: | 1730742172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IMAN | ||||||||
| FirstName: | FARDOWSA | ||||||||
| MiddleName: | HASSAN | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 524 25TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563033255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202021909 | ||||||||
| FaxNumber: | 3202021910 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 25TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563033255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202021909 | ||||||||
| FaxNumber: | 3202021910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 305423 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.