Provider Demographics
NPI:1104662691
Name:SAKALLAH, ALAA
Entity type:Individual
Prefix:
First Name:ALAA
Middle Name:
Last Name:SAKALLAH
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 1:3833 COON RAPIDS BLVD NW STE 100
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2697
Mailing Address - Country:US
Mailing Address - Phone:763-427-8320
Mailing Address - Fax:763-302-4338
Practice Address - Street 1:3833 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2643
Practice Address - Country:US
Practice Address - Phone:763-427-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP7069103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty