Provider Demographics
NPI:1346665247
Name:BAE, HEASUK (MFT)
Entity Type:Individual
Prefix:
First Name:HEASUK
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20955 PATHFINDER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4029
Mailing Address - Country:US
Mailing Address - Phone:909-938-4716
Mailing Address - Fax:909-397-0680
Practice Address - Street 1:20955 PATHFINDER RD STE 100
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765
Practice Address - Country:US
Practice Address - Phone:909-938-4716
Practice Address - Fax:909-938-4716
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-28
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT48583101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health