Provider Demographics
NPI:1154681476
Name:BALDWIN, WILLY C (LLC)
Entity Type:Individual
Prefix:
First Name:WILLY
Middle Name:C
Last Name:BALDWIN
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5883 BIBON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8317
Mailing Address - Country:US
Mailing Address - Phone:517-782-2908
Mailing Address - Fax:517-788-5998
Practice Address - Street 1:5883 BIBON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8317
Practice Address - Country:US
Practice Address - Phone:517-782-2908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012271101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health