Provider Demographics
NPI:1942869359
Name:BAE, CHRISTINE (LAC)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 OLD TAPPAN
Mailing Address - Street 2:BUILDING #3, 2ND FLOOR
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-1204
Mailing Address - Country:US
Mailing Address - Phone:845-535-1456
Mailing Address - Fax:
Practice Address - Street 1:180 OLD TAPPAN
Practice Address - Street 2:BUILDING #3, 2ND FLOOR
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-1204
Practice Address - Country:US
Practice Address - Phone:845-535-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00395500101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty