Healthcare Provider Details

I. General information

NPI: 1376191486
Provider Name (Legal Business Name): MS. CARLA ANDREA BAUCOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2019
Last Update Date: 09/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 W CENTRAL AVE STE 366E
TOLEDO OH
43606-1416
US

IV. Provider business mailing address

3450 W CENTRAL AVE STE 366E
TOLEDO OH
43606-1416
US

V. Phone/Fax

Practice location:
  • Phone: 419-531-2403
  • Fax: 419-531-2408
Mailing address:
  • Phone: 419-531-2403
  • Fax: 419-531-2403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: