Provider Demographics
NPI:1790882884
Name:BAXTER, LISA M (LISW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BAXTER
Suffix:
Gender:F
Credentials:LISW
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 4925
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4925
Mailing Address - Country:US
Mailing Address - Phone:515-643-6290
Mailing Address - Fax:515-643-6291
Practice Address - Street 1:411 LAUREL ST
Practice Address - Street 2:SUITE: 3310
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3017
Practice Address - Country:US
Practice Address - Phone:515-643-6290
Practice Address - Fax:515-643-6291
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA029131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI16516Medicare PIN