Healthcare Provider Details

I. General information

NPI: 1215450077
Provider Name (Legal Business Name): LAUREN KIM-BAE PH.D., L.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN BAE PH.D., L.P.

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 HIGHWAY 100 S
ST LOUIS PARK MN
55416-2175
US

IV. Provider business mailing address

6425 NICOLLET AVE
RICHFIELD MN
55423-1675
US

V. Phone/Fax

Practice location:
  • Phone: 52-915-4251
  • Fax: 952-920-2068
Mailing address:
  • Phone: 612-798-8187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP4302
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: