Provider Demographics
NPI:1972787976
Name:BAYLIS, AMY ADELE
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:ADELE
Last Name:BAYLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ADELE
Other - Last Name:CHAICLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2394
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8455
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:1126 S GOLD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-3768
Practice Address - Country:US
Practice Address - Phone:360-807-4929
Practice Address - Fax:360-807-4160
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60718696101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2139152Medicaid