Healthcare Provider Details

I. General information

NPI: 1184231540
Provider Name (Legal Business Name): CARSON BAUER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8398 MISSISSIPPI ST
MERRILLVILLE IN
46410-6316
US

IV. Provider business mailing address

1708 NORTHWOOD CT
VALPARAISO IN
46383-5129
US

V. Phone/Fax

Practice location:
  • Phone: 219-755-4049
  • Fax:
Mailing address:
  • Phone: 630-636-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-60212
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0-22-13505
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: