Basic Information
| Provider Information | |||||||||
| NPI: | 1942263983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PHD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | MR 10809 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122624813 | ||||||||
| FaxNumber: | 6122624194 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550572755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076630237 | ||||||||
| FaxNumber: | 5076631180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP0795 | MN | X | Behavioral Health & Social Service Providers | Psychologist | 106H00000X | 425 | MN | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.