Provider Demographics
NPI:1992518609
Name:BAEK, SEUNG AE
Entity type:Individual
Prefix:
First Name:SEUNG AE
Middle Name:
Last Name:BAEK
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 1:4055 N PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38152-6362
Mailing Address - Country:US
Mailing Address - Phone:217-819-2087
Mailing Address - Fax:
Practice Address - Street 1:4055 N PARK LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-4220
Practice Address - Country:US
Practice Address - Phone:217-819-2087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician