=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164675328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRISCILLA J. BAUDOIN MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2008
-----------------------------------------------------
Last Update Date | 03/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35393 AVENUE E
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-4828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-741-7973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1579 CASTLE PINES LN
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92223-8521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-769-4145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC20634
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------