Provider Demographics
NPI:1184767675
Name:BAKKE, BRUCE LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:BAKKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 IGLEHART AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5146
Mailing Address - Country:US
Mailing Address - Phone:651-645-3949
Mailing Address - Fax:651-645-3949
Practice Address - Street 1:3300 COUNTY ROAD 10
Practice Address - Street 2:SUITE 500
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-3072
Practice Address - Country:US
Practice Address - Phone:763-560-8331
Practice Address - Fax:763-560-8431
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2204103T00000X, 103TA0700X, 103TB0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN866750100Medicaid