Provider Demographics
NPI:1295546380
Name:GOSA, DIAMOND
Entity type:Individual
Prefix:
First Name:DIAMOND
Middle Name:
Last Name:GOSA
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 1:3850 BALLANTRAE RD APT 8
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1514
Mailing Address - Country:US
Mailing Address - Phone:708-791-8444
Mailing Address - Fax:
Practice Address - Street 1:110 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-1824
Practice Address - Country:US
Practice Address - Phone:507-301-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-16
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33966104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker