Provider Demographics
NPI:1669858676
Name:BAUER, MIRIAM (LMSW)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:BAUER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2257
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0357
Mailing Address - Country:US
Mailing Address - Phone:219-926-8320
Mailing Address - Fax:219-926-3524
Practice Address - Street 1:3180 RACQUET CLUB DR STE G
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4797
Practice Address - Country:US
Practice Address - Phone:231-933-4009
Practice Address - Fax:231-933-4032
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010849411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical