Provider Demographics
NPI:1548052921
Name:MOHAMUD, IDREES OMAR
Entity type:Individual
Prefix:
First Name:IDREES
Middle Name:OMAR
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 1:14701 PORTLAND AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-6408
Mailing Address - Country:US
Mailing Address - Phone:502-260-4491
Mailing Address - Fax:
Practice Address - Street 1:14701 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-6454
Practice Address - Country:US
Practice Address - Phone:502-260-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
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