Organization
LAKES PSYCHOLOGICAL PRACTICE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ANISA SOPHIA MOHAMMED PSYD, LP (PSYCHOLOGIST)
(612) 568-1475
Entity
Organization
Contact information
Practice address
100 FULLER ST S, SHAKOPEE, MN 55379-1348
(612) 568-1475
Mailing address
3248 STEVENS AVE, MINNEAPOLIS, MN 55408-3214
(813) 401-7624
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
LP5667
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1215364625
—
MN
Enumeration date
01/10/2018
Last updated
01/10/2018
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