Basic Information
| Provider Information | |||||||||
| NPI: | 1922737998 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALDWIN | ||||||||
| FirstName: | DEMETRIUS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1545 COMMERCIAL ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973024309 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 670 HAWTHORNE AVE SE STE 150 | ||||||||
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| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973016884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035894046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2022 | ||||||||
| LastUpdateDate: | 06/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | R7597 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.