Basic Information
| Provider Information | |||||||||
| NPI: | 1598114035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC/ ACADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
| FaxNumber: | 2086252070 | ||||||||
| Practice Location | |||||||||
| Address1: | 2205 IRONWOOD PI STE A/B | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086648347 | ||||||||
| FaxNumber: | 2086649217 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC6286 | ID | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 10300 | ID | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | ACADC11536 | ID | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | OPTUM1235503426 | 05 | ID | MEDICAID |