Provider Demographics
NPI:1740327881
Name:BAXTER, CORY WILLIAM (LCPC)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:WILLIAM
Last Name:BAXTER
Suffix:
Gender:M
Credentials:LCPC
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 616
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IL
Mailing Address - Zip Code:61727-0616
Mailing Address - Country:US
Mailing Address - Phone:217-935-9496
Mailing Address - Fax:
Practice Address - Street 1:1150 ROUTE 54 WEST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IL
Practice Address - Zip Code:61727
Practice Address - Country:US
Practice Address - Phone:217-935-9496
Practice Address - Fax:217-935-4508
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL18005753101YA0400X
IL180005753101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)