Healthcare Provider Details

I. General information

NPI: 1487983367
Provider Name (Legal Business Name): CONNIE DENNISE BALDWIN MS, LMHC(FL),LPC(TX)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3922 JACE DR
CRESTVIEW FL
32539-6510
US

IV. Provider business mailing address

405 OLDE POST RD
NICEVILLE FL
32578-3905
US

V. Phone/Fax

Practice location:
  • Phone: 210-885-5963
  • Fax:
Mailing address:
  • Phone: 210-885-5963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number63853
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10460723-6004
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH5223
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: