Provider Demographics
NPI:1982712956
Name:BALDREE, BRENT F (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:F
Last Name:BALDREE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4415
Mailing Address - Country:US
Mailing Address - Phone:208-552-5707
Mailing Address - Fax:208-552-5709
Practice Address - Street 1:1842 1ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4415
Practice Address - Country:US
Practice Address - Phone:208-552-5707
Practice Address - Fax:208-552-5709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY377103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDN6286OtherBLUE CROSS
ID000010155984OtherBLUE SHIELD
ID000010155984OtherBLUE SHIELD