Provider Demographics
NPI:1942915426
Name:BAILLIE, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:BAILLIE
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:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:KLAMATH
Mailing Address - State:CA
Mailing Address - Zip Code:95548-0502
Mailing Address - Country:US
Mailing Address - Phone:831-241-0406
Mailing Address - Fax:
Practice Address - Street 1:1680 E ROSEVILLE PKWY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3988
Practice Address - Country:US
Practice Address - Phone:831-241-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5513225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation