Provider Demographics
NPI:1639552383
Name:NATIVE LIFE
Entity Type:Organization
Organization Name:NATIVE LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PRACTITIONER/ED. PSYC
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA/MA/CSP/LCDC/CART
Authorized Official - Phone:210-606-1710
Mailing Address - Street 1:2017 W MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78201-4957
Mailing Address - Country:US
Mailing Address - Phone:210-606-1710
Mailing Address - Fax:
Practice Address - Street 1:2017 W MULBERRY AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78201-4957
Practice Address - Country:US
Practice Address - Phone:210-606-1710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8472101YA0400X
101YP1600X
AZ3556573103T00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty