Provider Demographics
NPI:1679317085
Name:TAR, JOHNETTE DIAMOND (MA)
Entity type:Individual
Prefix:
First Name:JOHNETTE
Middle Name:DIAMOND
Last Name:TAR
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 EDINA INDUSTRIAL BLVD STE 214
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55439-3005
Mailing Address - Country:US
Mailing Address - Phone:763-501-7368
Mailing Address - Fax:
Practice Address - Street 1:5100 EDINA INDUSTRIAL BLVD STE 214
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55439-3005
Practice Address - Country:US
Practice Address - Phone:763-501-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health