Provider Demographics
NPI:1467677336
Name:BAYLISS, JUSTIN A (OTRL)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:BAYLISS
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:CASTILE
Mailing Address - State:NY
Mailing Address - Zip Code:14427-9705
Mailing Address - Country:US
Mailing Address - Phone:585-322-3673
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569-1025
Practice Address - Country:US
Practice Address - Phone:585-786-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009620-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY166002571OtherTAX ID NUMBER