=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285839159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA MARIE BAK M.S., T.L.L.P.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1308 S MAIN ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-451-3440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15763 20 MILE RD
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49068-9455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-945-5133
-----------------------------------------------------
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 | 6301013458
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------