Provider Demographics
NPI:1194264549
Name:MOHAMED, OBSA
Entity type:Individual
Prefix:
First Name:OBSA
Middle Name:
Last Name:MOHAMED
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 1:2520 RHODE ISLAND AVE N APT 8
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-3590
Mailing Address - Country:US
Mailing Address - Phone:612-226-0907
Mailing Address - Fax:
Practice Address - Street 1:929 PORTLAND AVE APT 2407
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1277
Practice Address - Country:US
Practice Address - Phone:612-226-0907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN902963300022347C00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No347C00000XTransportation ServicesPrivate Vehicle