Provider Demographics
NPI:1346032604
Name:MOHAMUD, EDIRIS
Entity type:Individual
Prefix:
First Name:EDIRIS
Middle Name:
Last Name:MOHAMUD
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 1:10520 WAYZATA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1571
Mailing Address - Country:US
Mailing Address - Phone:612-919-2884
Mailing Address - Fax:612-404-1196
Practice Address - Street 1:10520 WAYZATA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MN
Practice Address - Zip Code:55305-1571
Practice Address - Country:US
Practice Address - Phone:612-919-2884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician