Basic Information
| Provider Information | |||||||||
| NPI: | 1770541237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | MILDRED | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 328 BASSLER ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166621417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149340303 | ||||||||
| FaxNumber: | 8147930916 | ||||||||
| Practice Location | |||||||||
| Address1: | 328 BASSLER ST | ||||||||
| Address2: | |||||||||
| City: | MARTINSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166621417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149340303 | ||||||||
| FaxNumber: | 8147930916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CW016550 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | SW012321L | 01 | PA | STATE SOCIAL WORK LICENSE | OTHER | 0077163600005 | 05 | PA | MEDICAID | CW016550 | 01 | PA | LCSW | OTHER |