Basic Information
| Provider Information | |||||||||
| NPI: | 1477063576 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAER | ||||||||
| FirstName: | BRITTANY | ||||||||
| MiddleName: | MICHELLE WISE | ||||||||
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| OtherLastName: | WISE | ||||||||
| OtherFirstName: | BRITTANY | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 N MADISON ST UNIT B | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600983301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063997616 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7360 N LINCOLN AVE STE 110 | ||||||||
| Address2: | |||||||||
| City: | LINCOLNWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 607121705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558552712 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2017 | ||||||||
| LastUpdateDate: | 10/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-27866 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.