Provider Demographics
NPI:1255527602
Name:LOU ANN BAYLOCK,LLC
Entity type:Organization
Organization Name:LOU ANN BAYLOCK,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-343-0321
Mailing Address - Street 1:193 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3423
Mailing Address - Country:US
Mailing Address - Phone:860-343-0321
Mailing Address - Fax:860-343-0321
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3423
Practice Address - Country:US
Practice Address - Phone:860-343-0321
Practice Address - Fax:860-343-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0051891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004246668-00Medicaid
CTD100007116Medicare PIN