Provider Demographics
NPI:1679397830
Name:BULHAN, FARDAWSA MOHAMED
Entity type:Individual
Prefix:
First Name:FARDAWSA
Middle Name:MOHAMED
Last Name:BULHAN
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 1:4186 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126
Mailing Address - Country:US
Mailing Address - Phone:612-644-8021
Mailing Address - Fax:
Practice Address - Street 1:4186 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126
Practice Address - Country:US
Practice Address - Phone:612-644-8021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician