Basic Information
| Provider Information | |||||||||
| NPI: | 1992732176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXTER | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | RHEAUME | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW, CAADC, CCDP-D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RHEAUME | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5054 PIERSONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIAVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484219343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107936794 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 420 W 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104964910 | ||||||||
| FaxNumber: | 8104964922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801067089 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | C-00472 | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0998084 | 01 | HEALTH PLUS | OTHER | 11558877 | 01 | AETNA | OTHER |