Healthcare Provider Details

I. General information

NPI: 1104424084
Provider Name (Legal Business Name): SUAD ISMAIL LPPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 PORTLAND AVE # MC963
MINNEAPOLIS MN
55415-1533
US

IV. Provider business mailing address

525 PORTLAND AVE # MC963
MINNEAPOLIS MN
55415-1533
US

V. Phone/Fax

Practice location:
  • Phone: 612-596-1223
  • Fax:
Mailing address:
  • Phone: 612-596-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC02519
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: