Provider Demographics
NPI:1124174172
Name:BAXTER, SUZANNE GARDNER (MA)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:GARDNER
Last Name:BAXTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 TRINITY LN
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3636
Mailing Address - Country:US
Mailing Address - Phone:610-834-1031
Mailing Address - Fax:610-834-1031
Practice Address - Street 1:978 TRINITY LN
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3636
Practice Address - Country:US
Practice Address - Phone:610-834-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003531-L103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool