Provider Demographics
NPI:1245882133
Name:BALEY, CHRISTIAN
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:BALEY
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 1:11202 MONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-7312
Mailing Address - Country:US
Mailing Address - Phone:813-830-3235
Mailing Address - Fax:813-409-3852
Practice Address - Street 1:13902 N DALE MABRY HWY STE 219
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2424
Practice Address - Country:US
Practice Address - Phone:813-830-3235
Practice Address - Fax:813-409-3852
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS.0102634171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113465300Medicaid