Provider Demographics
NPI:1568028850
Name:BAXTER, GRACE (LMSW-P)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:LMSW-P
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:LEEBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:605 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-4761
Mailing Address - Country:US
Mailing Address - Phone:509-703-0059
Mailing Address - Fax:
Practice Address - Street 1:1116 N MAIN ST STE M12
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3149
Practice Address - Country:US
Practice Address - Phone:580-925-0325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61115510101Y00000X, 390200000X
106S00000X
WANA60411306376K00000X
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program