Provider Demographics
NPI:1891486288
Name:BAUER, KRISTIN BERNELLE (MA, LAC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:BERNELLE
Last Name:BAUER
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 E WEATHERVANE LN
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-2143
Mailing Address - Country:US
Mailing Address - Phone:480-241-4840
Mailing Address - Fax:
Practice Address - Street 1:5410 S LAKESHORE DR STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2171
Practice Address - Country:US
Practice Address - Phone:480-485-8432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21601101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor