Provider Demographics
NPI:1417404708
Name:BAZA, ANTHONY (CSW)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BAZA
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 S 600 E STE 102
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2187
Mailing Address - Country:US
Mailing Address - Phone:801-382-8259
Mailing Address - Fax:
Practice Address - Street 1:254 S 600 E STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2187
Practice Address - Country:US
Practice Address - Phone:801-382-8259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-05
Last Update Date:2016-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9433374-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical