Basic Information
Provider Information
NPI: 1003004359
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BALDILLEZ
FirstName: JEREMY
MiddleName: JAMES
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 505 S MAIN ST
Address2: STE 249
City: LAS CRUCES
State: NM
PostalCode: 880011206
CountryCode: US
TelephoneNumber: 5055275823
FaxNumber: 5055275886
Practice Location
Address1: 3100 OAK ST
Address2:  
City: LAS CRUCES
State: NM
PostalCode: 880053425
CountryCode: US
TelephoneNumber: 5753233354
FaxNumber: 5755233354
Other Information
ProviderEnumerationDate: 10/11/2007
LastUpdateDate: 04/21/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TS0200X275299NMY Behavioral Health & Social Service ProvidersPsychologistSchool

No ID Information.


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