Provider Demographics
NPI:1134733314
Name:MOHAMUD, LAILA ABDULAZIZ
Entity type:Individual
Prefix:
First Name:LAILA
Middle Name:ABDULAZIZ
Last Name:MOHAMUD
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 1:500 FAIRWAY DR STE 102
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-1817
Mailing Address - Country:US
Mailing Address - Phone:877-418-2978
Mailing Address - Fax:866-500-2186
Practice Address - Street 1:601 S MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27110-0003
Practice Address - Country:US
Practice Address - Phone:336-750-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2021-12-29
Deactivation Date:2021-11-30
Deactivation Code:
Reactivation Date:2021-11-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC128652768001OtherBLUE CROSS BLUE SHIELD