Basic Information
| Provider Information | |||||||||
| NPI: | 1275948572 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKAEVA | ||||||||
| FirstName: | TATIANA | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPPIN STREET | ||||||||
| Address2: | COROWEST SUITE 202 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446551 | ||||||||
| FaxNumber: | 4014446587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2014 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 272919 | MA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | MD16734 | RI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.