Provider Demographics
NPI:1699463562
Name:BAUER, MAKAYLA VIRGINIA ROSE
Entity type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:VIRGINIA ROSE
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 1:2566 PARKVIEW DR APT 3
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-8208
Mailing Address - Country:US
Mailing Address - Phone:217-461-2531
Mailing Address - Fax:
Practice Address - Street 1:400 SAINT LOUIS ST STE 1
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1979
Practice Address - Country:US
Practice Address - Phone:618-226-4397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician