Provider Demographics
NPI:1972974913
Name:BAE, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23228 SESAME ST UNIT G
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-3034
Mailing Address - Country:US
Mailing Address - Phone:714-357-8188
Mailing Address - Fax:
Practice Address - Street 1:2447 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2714
Practice Address - Country:US
Practice Address - Phone:310-374-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20-1337841103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst