Provider Demographics
NPI:1619033610
Name:BALDASSARRE, BARBARA
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:
Last Name:BALDASSARRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 S. MADISON
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-917-9660
Mailing Address - Fax:
Practice Address - Street 1:504 S MADISON AVE.
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2801
Practice Address - Country:US
Practice Address - Phone:708-917-9660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0007807677OtherAETNA REGISTERED USER
IL01636273OtherBLUE SHIELD PROVIDER