Provider Demographics
NPI:1710575519
Name:BAEZ, OSVALDO
Entity Type:Individual
Prefix:
First Name:OSVALDO
Middle Name:
Last Name:BAEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2272 PORTOFINO BLVD
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-1292
Mailing Address - Country:US
Mailing Address - Phone:978-328-7168
Mailing Address - Fax:
Practice Address - Street 1:2272 PORTOFINO BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-1292
Practice Address - Country:US
Practice Address - Phone:978-328-7168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1154711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical