Provider Demographics
NPI:1699453530
Name:ABDALLA, SAMIRA O
Entity type:Individual
Prefix:
First Name:SAMIRA
Middle Name:O
Last Name:ABDALLA
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 1:14189 FERNDALE AVE NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1210
Mailing Address - Country:US
Mailing Address - Phone:952-454-3950
Mailing Address - Fax:
Practice Address - Street 1:14189 FERNDALE AVE NE
Practice Address - Street 2:
Practice Address - City:PRIOR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55372-1210
Practice Address - Country:US
Practice Address - Phone:952-454-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator