Provider Demographics
NPI:1003015645
Name:BAKER, STACY MICHELLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MICHELLE
Last Name:BAKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5149 HOUSEBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:KY
Mailing Address - Zip Code:42406-9765
Mailing Address - Country:US
Mailing Address - Phone:270-533-3525
Mailing Address - Fax:
Practice Address - Street 1:509 N CARRIER ST
Practice Address - Street 2:
Practice Address - City:MORGANFIELD
Practice Address - State:KY
Practice Address - Zip Code:42437-1201
Practice Address - Country:US
Practice Address - Phone:270-389-3515
Practice Address - Fax:270-389-4706
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R3387225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12500765Medicaid