Provider Demographics
NPI:1275705410
Name:BRENT F. BALDREE PH.D., INC.
Entity Type:Organization
Organization Name:BRENT F. BALDREE PH.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:F
Authorized Official - Last Name:BALDREE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-552-3050
Mailing Address - Street 1:2539 CHANNING WAY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7544
Mailing Address - Country:US
Mailing Address - Phone:208-552-3050
Mailing Address - Fax:
Practice Address - Street 1:2539 CHANNING WAY
Practice Address - Street 2:SUITE 260
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7544
Practice Address - Country:US
Practice Address - Phone:208-552-3050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY377261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)