=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205801610
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM STACY BALDWIN PHD LP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2006
-----------------------------------------------------
Last Update Date | 02/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 W 4TH ST
-----------------------------------------------------
City | RED WING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55066-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-267-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32073 LAKEVIEW DR
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55041-3256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | LP1728
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------