Provider Demographics
NPI:1487849568
Name:BALTAZAR, MAE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MAE
Middle Name:
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 US HWY 10 W
Mailing Address - Street 2:UNIT E
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047
Mailing Address - Country:US
Mailing Address - Phone:406-222-5519
Mailing Address - Fax:406-222-0366
Practice Address - Street 1:1201 US HWY 10 W
Practice Address - Street 2:UNIT E
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047
Practice Address - Country:US
Practice Address - Phone:406-222-5519
Practice Address - Fax:406-222-0366
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01208200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist