Healthcare Provider Details

I. General information

NPI: 1275510778
Provider Name (Legal Business Name): REENA PATHAK PSYD LP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W STE 229N
ST. PAUL MN
55114
US

IV. Provider business mailing address

3044 PARK AVE
MINNEAPOLIS MN
55407
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-3115
  • Fax: 651-645-2752
Mailing address:
  • Phone: 651-645-3115
  • Fax: 651-645-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4503
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: