=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497467401
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOUBACAR BAH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2022
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18740 W BLUEMOUND RD
-----------------------------------------------------
City | BROOKFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53045-2936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-470-3858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5454 FARGO AVE
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60077-3210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-470-3858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 17303-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 209.026536
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------