Basic Information
| Provider Information | |||||||||
| NPI: | 1396390415 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BAKER | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | C.O.T.A. OC 60984452 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25117 SW PARKWAY AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712242040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3121 SQUALICUM PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982251937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607346760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2019 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224ZE0001X | 60984452 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Environmental Modification | 224Z00000X | 60984452 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.