Basic Information
| Provider Information | |||||||||
| NPI: | 1891230603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAM | ||||||||
| FirstName: | MARIAM | ||||||||
| MiddleName: | YACOUB | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 UNIVERSITY AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127677222 | ||||||||
| FaxNumber: | 6128616050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 UNIVERSITY AVE SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554143325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127677222 | ||||||||
| FaxNumber: | 6128616050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2017 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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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 | 101YP2500X | CC01409 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.