Provider Demographics
NPI:1114640950
Name:SPROUSE, BAXTER
Entity Type:Individual
Prefix:
First Name:BAXTER
Middle Name:
Last Name:SPROUSE
Suffix:
Gender:M
Credentials:
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 708
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-0708
Mailing Address - Country:US
Mailing Address - Phone:360-708-1308
Mailing Address - Fax:
Practice Address - Street 1:851 SE PIONEER WAY STE 201
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5789
Practice Address - Country:US
Practice Address - Phone:360-333-5684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician