1922276195 NPI number — HEATHER LANAE BAJEMA PSY.D.

Table of content: HEATHER LANAE BAJEMA PSY.D. (NPI 1922276195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922276195 NPI number — HEATHER LANAE BAJEMA PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAJEMA
Provider First Name:
HEATHER
Provider Middle Name:
LANAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922276195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 E LUVERNE ST
Provider Second Line Business Mailing Address:
PO BOX 686
Provider Business Mailing Address City Name:
LUVERNE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56156-1610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-283-9511
Provider Business Mailing Address Fax Number:
507-283-9514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1024 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WORTHINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56187-2287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-376-4141
Provider Business Practice Location Address Fax Number:
507-376-4494
Provider Enumeration Date:
02/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP4893 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 360608000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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