Provider Demographics
NPI:1972795482
Name:BAXSTRUM, GUY TILLMAN JR (LMFT)
Entity Type:Individual
Prefix:MR
First Name:GUY
Middle Name:TILLMAN
Last Name:BAXSTRUM
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9540 CENTER AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5840
Mailing Address - Country:US
Mailing Address - Phone:909-980-2689
Mailing Address - Fax:
Practice Address - Street 1:9540 CENTER AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5840
Practice Address - Country:US
Practice Address - Phone:909-980-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT53065106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALMFT53065OtherBBS