Provider Demographics
NPI:1245249440
Name:BAXTER, ELIZABETH SUE (PHD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:S
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3368 SECOND AVE
Mailing Address - Street 2:STE A1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5666
Mailing Address - Country:US
Mailing Address - Phone:619-297-7174
Mailing Address - Fax:619-291-0901
Practice Address - Street 1:3368 SECOND AVE
Practice Address - Street 2:STE A1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5666
Practice Address - Country:US
Practice Address - Phone:619-297-7174
Practice Address - Fax:619-291-0901
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6647103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPG0066470Medicaid
CAPG0066470Medicaid