Provider Demographics
NPI:1619702628
Name:IBRAHIM, OSMAN NOOR
Entity type:Individual
Prefix:
First Name:OSMAN
Middle Name:NOOR
Last Name:IBRAHIM
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 1:16345 KENYON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8934
Mailing Address - Country:US
Mailing Address - Phone:612-978-0431
Mailing Address - Fax:
Practice Address - Street 1:16345 KENYON AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8934
Practice Address - Country:US
Practice Address - Phone:612-978-0431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician