Provider Demographics
NPI:1972239614
Name:BALTAZAR, AUXILIADORA
Entity Type:Individual
Prefix:
First Name:AUXILIADORA
Middle Name:
Last Name:BALTAZAR
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 778
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:CA
Mailing Address - Zip Code:93625-0778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:144 S L ST
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618-2323
Practice Address - Country:US
Practice Address - Phone:559-591-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1041C0700X
225C00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor