Healthcare Provider Details

I. General information

NPI: 1033259411
Provider Name (Legal Business Name): CHRISTINE TANDE JOHNSON PSYD LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 BROADWAY AVE NORTH FIVE COUNTY MENTAL HEALTH CENTER
BRAHAM MN
55006
US

IV. Provider business mailing address

FIVE COUNTY MENTAL HEALTH CENTER 521 BROADWAY AVENUE NORTH PO BOX 287
BRAHAM MN
55006
US

V. Phone/Fax

Practice location:
  • Phone: 320-396-3333
  • Fax: 320-396-3363
Mailing address:
  • Phone: 320-396-3333
  • Fax: 320-396-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP4704
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: