Healthcare Provider Details

I. General information

NPI: 1780171991
Provider Name (Legal Business Name): BAILEY BAKKEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BAILEY MCNAB

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39899 BALENTINE DR STE 110
NEWARK CA
94560-5356
US

IV. Provider business mailing address

PO BOX 740780
ATLANTA GA
30374-0780
US

V. Phone/Fax

Practice location:
  • Phone: 510-244-1145
  • Fax:
Mailing address:
  • Phone: 855-223-7123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-38866
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-43052
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: