Provider Demographics
NPI:1881060333
Name:GLENN BAXTER, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GLENN BAXTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 ST JOHN
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-8500
Mailing Address - Country:US
Mailing Address - Phone:360-510-9151
Mailing Address - Fax:
Practice Address - Street 1:510 US-160
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:MO
Practice Address - Zip Code:65606
Practice Address - Country:US
Practice Address - Phone:360-510-9151
Practice Address - Fax:833-415-0157
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023029159101YM0800X
WALH61301062101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor