Provider Demographics
NPI:1699129056
Name:MOHAMED, IFRAH YUSUF
Entity type:Individual
Prefix:
First Name:IFRAH
Middle Name:YUSUF
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 1:1304 E LAKE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1776
Mailing Address - Country:US
Mailing Address - Phone:612-822-1203
Mailing Address - Fax:612-871-2161
Practice Address - Street 1:1304 E LAKE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1776
Practice Address - Country:US
Practice Address - Phone:612-822-1203
Practice Address - Fax:612-871-2161
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22347104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN311700000XMedicaid