Provider Demographics
NPI:1710474499
Name:BANERJEE, SATABDI (LLPC, TLLP)
Entity Type:Individual
Prefix:
First Name:SATABDI
Middle Name:
Last Name:BANERJEE
Suffix:
Gender:F
Credentials:LLPC, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30734 BEECHWOOD ST APT 47111
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-2804
Mailing Address - Country:US
Mailing Address - Phone:908-630-7411
Mailing Address - Fax:
Practice Address - Street 1:1010 E WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3571
Practice Address - Country:US
Practice Address - Phone:248-313-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6401016552171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-1402860Medicaid