Healthcare Provider Details

I. General information

NPI: 1235613043
Provider Name (Legal Business Name): SHAIDA VAFAEI MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 210TH ST W
LAKEVILLE MN
55044-5707
US

IV. Provider business mailing address

2801 GIRARD AVE S APT 304
MINNEAPOLIS MN
55408-2048
US

V. Phone/Fax

Practice location:
  • Phone: 952-484-2211
  • Fax:
Mailing address:
  • Phone: 952-484-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: