Basic Information
| Provider Information | |||||||||
| NPI: | 1790005429 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILDRED BAKER LCSW LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | MILDRED BAKER SOLE MEMBER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 601 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | ROARING SPRING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166731351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149340303 | ||||||||
| FaxNumber: | 8143170341 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | ROARING SPRING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166731351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8149340303 | ||||||||
| FaxNumber: | 8143170341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2010 | ||||||||
| LastUpdateDate: | 06/04/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | MILDRED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8149340303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CW016550 | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.