Provider Demographics
NPI:1528454535
Name:DIVINE, RENEE (LMFT, CST)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:DIVINE
Suffix:
Gender:F
Credentials:LMFT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E 48TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-5651
Mailing Address - Country:US
Mailing Address - Phone:612-323-7222
Mailing Address - Fax:
Practice Address - Street 1:410 E 48TH ST STE 1
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55419-5651
Practice Address - Country:US
Practice Address - Phone:612-323-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2725106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist