=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952690471
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUE BAE, PHD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2011
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 405 N WABASH AVE SUITE 4507
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-441-1591
-----------------------------------------------------
Fax | 866-441-1136
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 405 N WABASH AVE SUITE 4507
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-441-1591
-----------------------------------------------------
Fax | 866-441-1136
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SUE BAE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 866-441-1591
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071006930
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------