Provider Demographics
NPI:1689044935
Name:BAUMGARTNER, KEN (MED)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:BAUMGARTNER
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2923
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-2923
Mailing Address - Country:US
Mailing Address - Phone:928-864-7165
Mailing Address - Fax:
Practice Address - Street 1:906 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-2986
Practice Address - Country:US
Practice Address - Phone:928-522-3780
Practice Address - Fax:928-563-0048
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1-15-21214103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst