Healthcare Provider Details

I. General information

NPI: 1487873535
Provider Name (Legal Business Name): JODI LYNN BAUER LPP,LBA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JODI LYNN MARTIN

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 RIDGEWOOD DR
MADISONVILLE KY
42431-9411
US

IV. Provider business mailing address

2325 RIDGEWOOD DR
MADISONVILLE KY
42431-9411
US

V. Phone/Fax

Practice location:
  • Phone: 270-339-0127
  • Fax:
Mailing address:
  • Phone: 270-339-0127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0108
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0048
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: