Basic Information
| Provider Information | |||||||||
| NPI: | 1881060333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN BAXTER | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GLENN | ||||||||
| OtherFirstName: | AMY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4526 FEDERAL AVE # MS 11 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982032132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253496200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 ST JOHN # 206 | ||||||||
| Address2: | |||||||||
| City: | THAYER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657918500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603950885 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MG61105058 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LH61301062 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor |
No ID Information.