Provider Demographics
NPI:1104669852
Name:MOHAMED, FENETI SALAHADIN
Entity type:Individual
Prefix:
First Name:FENETI
Middle Name:SALAHADIN
Last Name:MOHAMED
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 1:7264 WATERMARK WAY
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55038-4694
Mailing Address - Country:US
Mailing Address - Phone:763-447-7275
Mailing Address - Fax:
Practice Address - Street 1:7205 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-3134
Practice Address - Country:US
Practice Address - Phone:612-208-0729
Practice Address - Fax:612-354-3801
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician