Provider Demographics
NPI:1932913746
Name:FARAH, FARDOSA ABDULLAH
Entity type:Individual
Prefix:
First Name:FARDOSA
Middle Name:ABDULLAH
Last Name:FARAH
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 1:6265 MONTICELLO LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6285
Mailing Address - Country:US
Mailing Address - Phone:612-707-0477
Mailing Address - Fax:
Practice Address - Street 1:10650 RED CIRCLE DR STE 320
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9117
Practice Address - Country:US
Practice Address - Phone:612-987-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician