Provider Demographics
NPI:1215364625
Name:MOHAMMED, ANISA SOPHIA (PSYD, LP)
Entity type:Individual
Prefix:
First Name:ANISA
Middle Name:SOPHIA
Last Name:MOHAMMED
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 4TH AVE W
Mailing Address - Street 2:#300
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-1220
Mailing Address - Country:US
Mailing Address - Phone:952-496-8614
Mailing Address - Fax:
Practice Address - Street 1:200 4TH AVE W
Practice Address - Street 2:#300
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-1220
Practice Address - Country:US
Practice Address - Phone:952-496-8614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5667103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical