Provider Demographics
NPI:1457377277
Name:BAXT, ELIZABETH TRACY
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:TRACY
Last Name:BAXT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1366 CLEMSON AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3041
Mailing Address - Country:US
Mailing Address - Phone:909-518-0329
Mailing Address - Fax:909-596-4955
Practice Address - Street 1:150 N GRAND AVE STE 212
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1757
Practice Address - Country:US
Practice Address - Phone:626-915-2119
Practice Address - Fax:909-596-4955
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC20764106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist