Provider Demographics
NPI:1497755979
Name:BALDICK, THEODORE L (PHD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:L
Last Name:BALDICK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-7602
Mailing Address - Country:US
Mailing Address - Phone:901-458-6291
Mailing Address - Fax:901-323-4848
Practice Address - Street 1:3950 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-7602
Practice Address - Country:US
Practice Address - Phone:901-458-6291
Practice Address - Fax:901-323-4848
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS27365103T00000X
TNP0000000685103TA0400X, 103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0009713OtherTN BLUE SHIELD
TN2033550OtherCIGNA
TN2033550OtherCIGNA