Provider Demographics
NPI:1437499886
Name:BAXTER-MUSSER, KATELYN ELIZABETH (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:BAXTER-MUSSER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:ELIZABETH
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:165 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2406
Practice Address - Country:US
Practice Address - Phone:207-874-1030
Practice Address - Fax:207-874-1044
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC144381041C0700X
AZLCSW 137471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400181983Medicare PIN
MEE400157853Medicare PIN