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General NPI Number Information
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NPI Number | 1497755979
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Entity Type | Individual
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Provider Name | THEODORE L BALDICK PH.D.
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Gender | Male
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Dates
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Enumeration Date | 07/27/2005
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Last Update Date | 02/04/2008
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Provider Practice Location Address
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Address Line | 3950 CENTRAL AVE
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City | MEMPHIS
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State | TN
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Zip | 38111-7602
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Country | US
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Telephone | 901-458-6291
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Fax | 901-323-4848
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Provider Business Mailing Address
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Address Line | 3950 CENTRAL AVE
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City | MEMPHIS
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State | TN
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Zip | 38111-7602
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Country | US
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Telephone | 901-458-6291
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Fax | 901-323-4848
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 27365
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number | P0000000685
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | P0000000685
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License Number State | TN
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Taxonomy #4
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | P0000000685
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License Number State | TN
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