Provider Demographics
NPI:1710286976
Name:BAITMAN, KELLY C JACKSON (LSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:C JACKSON
Last Name:BAITMAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2681 STANTON CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-6255
Mailing Address - Country:US
Mailing Address - Phone:757-846-6932
Mailing Address - Fax:
Practice Address - Street 1:2681 STANTON CIR
Practice Address - Street 2:
Practice Address - City:LAKE IN THE HILLS
Practice Address - State:IL
Practice Address - Zip Code:60156-6255
Practice Address - Country:US
Practice Address - Phone:757-846-6932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.009815104100000X
IL20879101041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool