Provider Demographics
NPI:1083490908
Name:BAEZA, CARMIN
Entity Type:Individual
Prefix:
First Name:CARMIN
Middle Name:
Last Name:BAEZA
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 1:2603 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-6210
Mailing Address - Country:US
Mailing Address - Phone:620-789-0111
Mailing Address - Fax:
Practice Address - Street 1:2603 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-6210
Practice Address - Country:US
Practice Address - Phone:620-789-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician