Provider Demographics
NPI:1992282255
Name:SUAZO BAEZ, KARY DAVIELA
Entity type:Individual
Prefix:
First Name:KARY
Middle Name:DAVIELA
Last Name:SUAZO BAEZ
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 1:180 FELLSWAY W APT 3
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-2061
Mailing Address - Country:US
Mailing Address - Phone:617-401-5374
Mailing Address - Fax:
Practice Address - Street 1:180 FELLSWAY W APT 3
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-2061
Practice Address - Country:US
Practice Address - Phone:617-401-5374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
MALICSW11205661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No251S00000XAgenciesCommunity/Behavioral Health