Provider Demographics
NPI:1124110929
Name:BAXTER, CAROL (MSW)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:BAXTER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:BAXTER-PULICE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:416 PEQUOT AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890
Mailing Address - Country:US
Mailing Address - Phone:203-209-4136
Mailing Address - Fax:
Practice Address - Street 1:2228 BLACK ROCK TURNPIKE
Practice Address - Street 2:SUITE 311
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825
Practice Address - Country:US
Practice Address - Phone:203-366-2552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT 0007501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT80000143Medicare ID - Type Unspecified