Provider Demographics
NPI:1386711604
Name:BARON, MICHAEL PHILIP (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILIP
Last Name:BARON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2848
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-2848
Mailing Address - Country:US
Mailing Address - Phone:505-843-7279
Mailing Address - Fax:
Practice Address - Street 1:696 MISSION VALLEY RD
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-2848
Practice Address - Country:US
Practice Address - Phone:505-843-7279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM208103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN5970Medicaid