Provider Demographics
NPI:1891374807
Name:BANERJEE, REKHA MIRIAM (LICSW, LADC)
Entity Type:Individual
Prefix:
First Name:REKHA
Middle Name:MIRIAM
Last Name:BANERJEE
Suffix:
Gender:F
Credentials:LICSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 E FRANKLIN AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-2977
Mailing Address - Country:US
Mailing Address - Phone:612-843-6824
Mailing Address - Fax:
Practice Address - Street 1:1113 E FRANKLIN AVE STE 202
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2977
Practice Address - Country:US
Practice Address - Phone:612-843-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302853101YA0400X
MN272201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)