Provider Demographics
NPI:1861661035
Name:BAXTER, BETH CLEVENGER (MA LCPC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:CLEVENGER
Last Name:BAXTER
Suffix:
Gender:F
Credentials:MA LCPC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:CLEVENGER
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA LLP
Mailing Address - Street 1:800 W 5TH AVE STE 205I
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8965
Mailing Address - Country:US
Mailing Address - Phone:630-779-0751
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE STE 205I
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8965
Practice Address - Country:US
Practice Address - Phone:630-779-0751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010760103TC0700X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical