Basic Information
| Provider Information | |||||||||
| NPI: | 1790428985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALDRIDGE | ||||||||
| FirstName: | TAYLOR | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2477 CURTIS CT | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625016504 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1727 SHAWANO AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543033268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 726426 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 726426 | 01 | WI | WI STATE | OTHER |