Provider Demographics
NPI:1780099663
Name:BAEZ, WANDA M
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:M
Last Name:BAEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:WANDA
Other - Middle Name:M
Other - Last Name:BAEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NONE
Mailing Address - Street 1:150 W 225TH ST APT 7C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-5043
Mailing Address - Country:US
Mailing Address - Phone:917-355-3385
Mailing Address - Fax:
Practice Address - Street 1:150 W 225TH ST APT 7C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5043
Practice Address - Country:US
Practice Address - Phone:917-355-3385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency