Provider Demographics
NPI:1629001532
Name:BAILLIE-JOHNSON, PAMELA RUTH (MA, LMFT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:RUTH
Last Name:BAILLIE-JOHNSON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:RUTH
Other - Last Name:BAILLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4815 BURNING TREE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3800
Mailing Address - Country:US
Mailing Address - Phone:218-464-0908
Mailing Address - Fax:218-722-4400
Practice Address - Street 1:4815 BURNING TREE RD STE 106
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3800
Practice Address - Country:US
Practice Address - Phone:218-464-0908
Practice Address - Fax:218-722-4400
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1267106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN630131200Medicaid