Provider Demographics
NPI:1194449249
Name:ROBERTSON, JULIANA RENEE (LICSW)
Entity type:Individual
Prefix:
First Name:JULIANA
Middle Name:RENEE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3578 KIMMUR RD SW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5821
Mailing Address - Country:US
Mailing Address - Phone:507-319-2365
Mailing Address - Fax:
Practice Address - Street 1:24760 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:REDLAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-0168
Practice Address - Fax:218-679-0187
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN278821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty