Basic Information
Provider Information | |||||||||
NPI: | 1427248285 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALDWIN-GARDUNO | ||||||||
FirstName: | LILY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS, MENTAL HEALTH CO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BALDWIN-GARDUNO | ||||||||
OtherFirstName: | LILY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MS | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3350 AIRPORT DR | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982268048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607345458 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3350 AIRPORT DR | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982268048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607345458 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2007 | ||||||||
LastUpdateDate: | 04/02/2019 | ||||||||
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 | 101YM0800X | LH00003629 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 2003519 | 05 | WA |   | MEDICAID |