Healthcare Provider Details

I. General information

NPI: 1669828828
Provider Name (Legal Business Name): LARRY BAUMGARTNER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2016
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7747 MITCHELL BLVD STE B
TRINITY FL
34655-4725
US

IV. Provider business mailing address

7747 MITCHELL BLVD STE B
TRINITY FL
34655-4725
US

V. Phone/Fax

Practice location:
  • Phone: 727-946-1346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMT2376
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: