Provider Demographics
NPI:1679603351
Name:BAXENDALE, STEPHEN HAROLD (LICSW)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:HAROLD
Last Name:BAXENDALE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 COUNTY ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-4606
Mailing Address - Country:US
Mailing Address - Phone:508-226-7523
Mailing Address - Fax:
Practice Address - Street 1:140 PARK ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-3064
Practice Address - Country:US
Practice Address - Phone:508-222-7525
Practice Address - Fax:508-223-4145
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1016251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30062-5OtherBLUE CROSS OF RHODE ISLAN
MA1309161Medicaid
MA1309161Medicaid