Provider Demographics
NPI:1033827217
Name:BALDUC, MARY JO
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:BALDUC
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 1:1612 S WOOLSEY ST
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:MI
Mailing Address - Zip Code:49911-1830
Mailing Address - Country:US
Mailing Address - Phone:906-364-0538
Mailing Address - Fax:
Practice Address - Street 1:101 E MARY ST STE 5
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:MI
Practice Address - Zip Code:49911-1457
Practice Address - Country:US
Practice Address - Phone:906-285-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022588101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional