Healthcare Provider Details

I. General information

NPI: 1053034454
Provider Name (Legal Business Name): ASMA MOUDI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 80TH ST S # 100
COTTAGE GROVE MN
55016-3008
US

IV. Provider business mailing address

7500 80TH ST S # 100
COTTAGE GROVE MN
55016-3008
US

V. Phone/Fax

Practice location:
  • Phone: 763-999-8041
  • Fax:
Mailing address:
  • Phone: 763-999-8041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-88292
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: