Provider Demographics
NPI:1427398072
Name:BAISCH, BRENT (LMT)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:BAISCH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 BOARDMAN CANFIELD RD
Mailing Address - Street 2:SUITE P1
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4300
Mailing Address - Country:US
Mailing Address - Phone:330-726-7404
Mailing Address - Fax:330-729-9166
Practice Address - Street 1:755 BOARDMAN CANFIELD RD
Practice Address - Street 2:SUITE P1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4300
Practice Address - Country:US
Practice Address - Phone:330-726-7404
Practice Address - Fax:330-729-9166
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.014324-A-B225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist