Healthcare Provider Details

I. General information

NPI: 1245387828
Provider Name (Legal Business Name): ROBERT DOUGLAS BAIZE CDP, NCAC I, MHP,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 E MAIN ST
BLOOMFIELD IN
47424-1460
US

IV. Provider business mailing address

PO BOX 653
SEDRO WOOLLEY WA
98284-0653
US

V. Phone/Fax

Practice location:
  • Phone: 812-384-9452
  • Fax: 812-384-9445
Mailing address:
  • Phone: 425-349-8226
  • Fax: 425-349-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00005724
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH00005969
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003718A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: