Provider Demographics
NPI:1528502101
Name:FROERER, BAYLEE
Entity type:Individual
Prefix:
First Name:BAYLEE
Middle Name:
Last Name:FROERER
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 1:4460 S HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3543
Mailing Address - Country:US
Mailing Address - Phone:435-230-1151
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3543
Practice Address - Country:US
Practice Address - Phone:801-263-7101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-15
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT10836981-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
UT000055266Medicare PIN