Provider Demographics
NPI:1154830362
Name:BALDWIN, DAVID RICHARD (CP00006153)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:RICHARD
Last Name:BALDWIN
Suffix:
Gender:M
Credentials:CP00006153
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 67
Mailing Address - Street 2:EAST STATE STREET
Mailing Address - City:MOSSYROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98564
Mailing Address - Country:US
Mailing Address - Phone:360-983-3227
Mailing Address - Fax:360-983-3289
Practice Address - Street 1:230 EAST STATE STREET
Practice Address - Street 2:
Practice Address - City:MOSSYROCK
Practice Address - State:WA
Practice Address - Zip Code:98564
Practice Address - Country:US
Practice Address - Phone:360-983-3257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00006153101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1991983Medicaid