Provider Demographics
NPI:1275510778
Name:PATHAK, REENA (PSYD LP)
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:
Last Name:PATHAK
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407
Mailing Address - Country:US
Mailing Address - Phone:651-645-3115
Mailing Address - Fax:651-645-2752
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:STE 229N
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114
Practice Address - Country:US
Practice Address - Phone:651-645-3115
Practice Address - Fax:651-645-2752
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4503103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNOIN02PAOtherBCBS OF MN