Provider Demographics
NPI:1922480656
Name:BAXTER, TIA J
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:J
Last Name:BAXTER
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 1:1033 BALDY MT ROAD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83813
Mailing Address - Country:US
Mailing Address - Phone:503-435-8325
Mailing Address - Fax:
Practice Address - Street 1:500 N GILWOOD ST
Practice Address - Street 2:
Practice Address - City:CARLTON
Practice Address - State:OR
Practice Address - Zip Code:97111
Practice Address - Country:US
Practice Address - Phone:503-435-8325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4774225700000X
OR21021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist