Provider Demographics
NPI:1184874158
Name:BALTAZAR, ALINA MCBRIDE (MSW)
Entity type:Individual
Prefix:
First Name:ALINA
Middle Name:MCBRIDE
Last Name:BALTAZAR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 MINERS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9625
Mailing Address - Country:US
Mailing Address - Phone:269-408-1688
Mailing Address - Fax:269-408-1692
Practice Address - Street 1:1030 MINERS RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9625
Practice Address - Country:US
Practice Address - Phone:269-408-1688
Practice Address - Fax:269-408-1692
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010708201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P14210Medicare PIN