Provider Demographics
NPI:1336932532
Name:ELMI, SOUBANE OMAR
Entity type:Individual
Prefix:
First Name:SOUBANE
Middle Name:OMAR
Last Name:ELMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 UNIVERSITY AVE W STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4785
Mailing Address - Country:US
Mailing Address - Phone:612-850-3018
Mailing Address - Fax:612-545-4845
Practice Address - Street 1:995 UNIVERSITY AVE W STE 202
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4785
Practice Address - Country:US
Practice Address - Phone:612-850-3018
Practice Address - Fax:612-545-4845
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician