Basic Information
| Provider Information | |||||||||
| NPI: | 1053818823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | TREVOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4807 HEATHER PASS | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782182748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2544669030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3615 CULEBRA RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782285914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103146473 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1457793861 | 05 | TX | MEDICAID |