=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255527602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOU ANN BAYLOCK,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2007
-----------------------------------------------------
Last Update Date | 10/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 193 MAIN ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-3423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-343-0321
-----------------------------------------------------
Fax | 860-343-0321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 193 MAIN ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-3423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-343-0321
-----------------------------------------------------
Fax | 860-343-0321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MS. LOUISE ANN BAYLOCK
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-343-0321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 005189
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------