MEDICARE: FATHI ABDULLAHI KOFIRO LICSW

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	1041C0700X	Clinical Social Worker	27112	MN

General Provider Information

NPI Number	:	1649851197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATHI ABDULLAHI KOFIRO LICSW

Provider Business Mailing Address
First Line	:	1509 W 86TH ST
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55431-2071
Country	:	US
Telephone Number	:	763-209-8263
Fax Number	:

Provider Business Practice Location Address
First Line	:	8030 OLD CEDAR AVE S
Second Line	:
City	:	BLOOMINGTON
State	:	MN
Zip	:	55425-1213
Country	:	US
Telephone Number	:	763-209-8263
Fax Number	:

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

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	07/23/2025

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