Provider Demographics
NPI:1972786135
Name:BAEZA, JOSE L
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:BAEZA
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOSE
Other - Middle Name:L
Other - Last Name:BAEZA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:BUENA HIGH SCHOOL
Mailing Address - Street 2:5225 E. BUENA SCHOOL BLVD
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635
Mailing Address - Country:US
Mailing Address - Phone:520-559-1326
Mailing Address - Fax:520-515-3091
Practice Address - Street 1:5225 E BUENA SCHOOL BLVD
Practice Address - Street 2:ALC
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2392
Practice Address - Country:US
Practice Address - Phone:520-559-1326
Practice Address - Fax:520-515-3091
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool