MEDICARE: SUMAYA MAHAMUD

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	106S00000X	Behavior Technician		MN

General Provider Information

NPI Number	:	1417782798
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUMAYA MAHAMUD

Provider Business Mailing Address
First Line	:	1096 SIMS AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55106-3925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 UNIVERSITY AVE W STE 169
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-2803
Country	:	US
Telephone Number	:	651-348-3897
Fax Number	:

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

Provider Enumeration Date	:	09/05/2024
Last Update Date	:	09/05/2024

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Directions to “ SUMAYA MAHAMUD ” Practice Location

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