Provider Demographics
NPI:1154792315
Name:BAIRD, GWENDOLYN
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:BAIRD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2268 E COURTLAND DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6194
Mailing Address - Country:US
Mailing Address - Phone:208-761-2618
Mailing Address - Fax:
Practice Address - Street 1:245 N 3RD E
Practice Address - Street 2:
Practice Address - City:MT HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-2734
Practice Address - Country:US
Practice Address - Phone:208-587-8255
Practice Address - Fax:208-587-4475
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-542225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist