Provider Demographics
NPI:1518512375
Name:MOHAMED, SAMSAM O
Entity type:Individual
Prefix:MS
First Name:SAMSAM
Middle Name:O
Last Name:MOHAMED
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 1:3055 OLD HIGHWAY 8 STE 101F
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-2500
Mailing Address - Country:US
Mailing Address - Phone:612-259-7715
Mailing Address - Fax:612-259-7889
Practice Address - Street 1:3055 OLD HIGHWAY 8 STE 101F
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-2500
Practice Address - Country:US
Practice Address - Phone:612-259-7715
Practice Address - Fax:612-259-7889
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency