Provider Demographics
NPI:1912352550
Name:BAIZA, RAQUE;
Entity Type:Individual
Prefix:
First Name:RAQUE;
Middle Name:
Last Name:BAIZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:BAIZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SSW
Mailing Address - Street 1:532 N DEXTER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84116-2780
Mailing Address - Country:US
Mailing Address - Phone:801-808-1389
Mailing Address - Fax:
Practice Address - Street 1:532 N DEXTER ST APT 3
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84116-2780
Practice Address - Country:US
Practice Address - Phone:801-808-1389
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker