MEDICARE: FEKRI MOHAMED IBRAHIM

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	:	1750028478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FEKRI MOHAMED IBRAHIM

Provider Business Mailing Address
First Line	:	2520 E HENNEPIN AVE UNIT D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2912
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 E HENNEPIN AVE UNIT D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2912
Country	:	US
Telephone Number	:	612-481-5749
Fax Number	:

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

Provider Enumeration Date	:	05/14/2022
Last Update Date	:	05/14/2022

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