Provider Demographics
NPI:1952965279
Name:BAXTER, STEPHANIE DIANNE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DIANNE
Last Name:BAXTER
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 1:1057 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2509
Mailing Address - Country:US
Mailing Address - Phone:360-636-3892
Mailing Address - Fax:360-232-8400
Practice Address - Street 1:831 12TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2403
Practice Address - Country:US
Practice Address - Phone:360-998-2349
Practice Address - Fax:360-998-2887
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC60614734101YM0800X
WALW60990251104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2146977Medicaid