Provider Demographics
NPI:1891487583
Name:BAEZ, TATIANA MALYSE
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:MALYSE
Last Name:BAEZ
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 1:51 ROUND HILL ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1222
Mailing Address - Country:US
Mailing Address - Phone:857-719-6191
Mailing Address - Fax:
Practice Address - Street 1:891 CENTRE ST STE 300
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2777
Practice Address - Country:US
Practice Address - Phone:978-648-8515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health