Healthcare Provider Details

I. General information

NPI: 1659980043
Provider Name (Legal Business Name): ILYAS MAYE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W LAKE ST APT 331
MINNEAPOLIS MN
55408-6101
US

IV. Provider business mailing address

410 W LAKE ST APT 331
MINNEAPOLIS MN
55408-6101
US

V. Phone/Fax

Practice location:
  • Phone: 612-407-4245
  • Fax:
Mailing address:
  • Phone: 612-407-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: