Provider Demographics
NPI:1225569338
Name:BAUMGARTNER, TABATHA JO (LCSW)
Entity type:Individual
Prefix:
First Name:TABATHA
Middle Name:JO
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TABATHA
Other - Middle Name:JO
Other - Last Name:CARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:402 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1619
Mailing Address - Country:US
Mailing Address - Phone:208-650-7941
Mailing Address - Fax:208-436-0735
Practice Address - Street 1:512 6TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1621
Practice Address - Country:US
Practice Address - Phone:208-436-4911
Practice Address - Fax:208-436-1758
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-36530104100000X
IDLCSW-448781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker