Provider Demographics
NPI:1154477362
Name:BAXLEY, BRUCE CARROLL (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CARROLL
Last Name:BAXLEY
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 964
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-0964
Mailing Address - Country:US
Mailing Address - Phone:858-271-3060
Mailing Address - Fax:
Practice Address - Street 1:4405 MANCHESTER AVE STE 206
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7902
Practice Address - Country:US
Practice Address - Phone:858-271-3060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6399103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY063990Medicaid
CAPSY063990Medicaid