Provider Demographics
NPI:1255775714
Name:BAUER, RACHEL
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:BAUER
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 1:1324 LAKE DR SE STE 5
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1673
Mailing Address - Country:US
Mailing Address - Phone:616-717-3935
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKE DR SE STE 5
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1673
Practice Address - Country:US
Practice Address - Phone:616-717-3935
Practice Address - Fax:313-221-8393
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-26
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093067104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI9403Medicare PIN