Provider Demographics
NPI:1902525884
Name:SIYAT, IDRISS ABDIKADIR
Entity Type:Individual
Prefix:
First Name:IDRISS
Middle Name:ABDIKADIR
Last Name:SIYAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 E LAKE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1629
Mailing Address - Country:US
Mailing Address - Phone:612-298-2169
Mailing Address - Fax:
Practice Address - Street 1:1315 E LAKE ST STE 1
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1629
Practice Address - Country:US
Practice Address - Phone:612-298-2169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician