Provider Demographics
NPI:1083445241
Name:DHIISOW, MAHAD A
Entity type:Individual
Prefix:
First Name:MAHAD
Middle Name:A
Last Name:DHIISOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7533 SHERIDAN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-3559
Mailing Address - Country:US
Mailing Address - Phone:507-351-1640
Mailing Address - Fax:
Practice Address - Street 1:7533 SHERIDAN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-3559
Practice Address - Country:US
Practice Address - Phone:507-351-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No374700000XNursing Service Related ProvidersTechnician