Provider Demographics
NPI:1629367545
Name:BAXTER, BRIAN W (LCSW, CASAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:BAXTER
Suffix:
Gender:M
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 FULTON STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:347-505-0160
Mailing Address - Fax:
Practice Address - Street 1:1125 FULTON ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-2669
Practice Address - Country:US
Practice Address - Phone:347-505-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075155-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical