Basic Information
Provider Information | |||||||||
NPI: | 1396727897 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BAUGH | ||||||||
FirstName: | JUDY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | LSCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4505 E 47TH ST S | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672101651 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3116529910 | ||||||||
FaxNumber: | 3165299351 | ||||||||
Practice Location | |||||||||
Address1: | 17 OLIVE ST. | ||||||||
Address2: | BOX 207 | ||||||||
City: | CONCORDIA | ||||||||
State: | KS | ||||||||
PostalCode: | 669014934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7852434236 | ||||||||
FaxNumber: | 7852436119 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2005 | ||||||||
LastUpdateDate: | 02/08/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2282 | KS | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 200373160A | 05 | KS |   | MEDICAID |