Basic Information
| Provider Information | |||||||||
| NPI: | 1386396091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLETAR | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MSW, LGSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1527 E LAKE ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554076700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6127290340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5910 SHINGLE CREEK PKWY STE 7 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554302323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634503383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2022 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 30198 | MN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.