MEDICARE: MEYMUN MOHAMED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1205466042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEYMUN MOHAMED

Provider Business Mailing Address
First Line	:	4236 PARK GLEN RD
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4758
Country	:	US
Telephone Number	:	612-636-7188
Fax Number	:	612-605-3312

Provider Business Practice Location Address
First Line	:	4236 PARK GLEN RD
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4758
Country	:	US
Telephone Number	:	612-636-7188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2020
Last Update Date	:	01/21/2020

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