Provider Demographics
NPI:1770630303
Name:BAZE, MALINDA S (LCSW)
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:S
Last Name:BAZE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 N COLE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4403
Mailing Address - Country:US
Mailing Address - Phone:208-378-1122
Mailing Address - Fax:208-323-9070
Practice Address - Street 1:3308 N COLE RD
Practice Address - Street 2:SUITE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4403
Practice Address - Country:US
Practice Address - Phone:208-378-1122
Practice Address - Fax:208-323-9070
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW263751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010150794OtherREGENCE BLUE SHIELD OF ID
IDL5963OtherBLUE CROSS OF IDAHO