Provider Demographics
NPI:1497849509
Name:BAKKEN, JOEL T (MS LP)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:T
Last Name:BAKKEN
Suffix:
Gender:M
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 BELSLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5055
Mailing Address - Country:US
Mailing Address - Phone:218-287-4338
Mailing Address - Fax:218-287-5928
Practice Address - Street 1:891 BELSLY BLVD
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5055
Practice Address - Country:US
Practice Address - Phone:218-287-4338
Practice Address - Fax:218-287-5928
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0872103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN448852100Medicaid
MN140L6BAOtherBLUE CROSS
MN140L6BAOtherBLUE CROSS