Provider Demographics
NPI:1932919784
Name:IBRAHIM, SAMMIYA JAMAL
Entity type:Individual
Prefix:
First Name:SAMMIYA
Middle Name:JAMAL
Last Name:IBRAHIM
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 1:8085 WAYZATA BLVD STE 100 GOLDEN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124
Mailing Address - Country:US
Mailing Address - Phone:763-312-3123
Mailing Address - Fax:763-316-3123
Practice Address - Street 1:7630 145TH ST W
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7553
Practice Address - Country:US
Practice Address - Phone:612-986-4834
Practice Address - Fax:612-448-2633
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician