Provider Demographics
NPI:1518047349
Name:BAXTER, THERESA PAYNTER (PT, LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:PAYNTER
Last Name:BAXTER
Suffix:
Gender:F
Credentials:PT, LCSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:PAYNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, PT
Mailing Address - Street 1:5249 EL CEMONTE AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4417
Mailing Address - Country:US
Mailing Address - Phone:530-746-8573
Mailing Address - Fax:
Practice Address - Street 1:133 D ST STE J
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4695
Practice Address - Country:US
Practice Address - Phone:707-391-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12659225100000X
390200000X
CA810991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT126591OtherMEDICARE PTAN