Provider Demographics
NPI:1104378256
Name:BAETZ, CARLY (JD, PHD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BAETZ
Suffix:
Gender:F
Credentials:JD, PHD
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:BAETZ-STANGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:443 17TH ST
Mailing Address - Street 2:APT 2L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-6233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 NATHAN D PERLMAN PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3851
Practice Address - Country:US
Practice Address - Phone:917-409-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021885103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical