Provider Demographics
NPI:1225152119
Name:BAXTER, WANDA M (PSYD)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:M
Last Name:BAXTER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 MAPLEPLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-6051
Mailing Address - Country:US
Mailing Address - Phone:916-421-9329
Mailing Address - Fax:
Practice Address - Street 1:1321 HOWE AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3365
Practice Address - Country:US
Practice Address - Phone:916-391-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19373103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical