Provider Demographics
NPI:1497762215
Name:BAXTER, KATHLEEN ALYCE (MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ALYCE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1004
Mailing Address - Country:US
Mailing Address - Phone:530-750-3631
Mailing Address - Fax:530-758-7099
Practice Address - Street 1:1747 OAK AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1004
Practice Address - Country:US
Practice Address - Phone:530-750-3631
Practice Address - Fax:530-758-7099
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40532106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist