Provider Demographics
NPI:1265687669
Name:BAILEY, JOHN ROGER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROGER
Last Name:BAILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 S ALBANY ST STE 5
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5446
Mailing Address - Country:US
Mailing Address - Phone:606-216-1450
Mailing Address - Fax:607-216-1461
Practice Address - Street 1:108 S ALBANY ST STE 5
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5446
Practice Address - Country:US
Practice Address - Phone:606-216-1450
Practice Address - Fax:607-216-1461
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004150101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health