Provider Demographics
NPI:1003926288
Name:BAKER, THERESA E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:E
Last Name:BAKER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3936
Mailing Address - Country:US
Mailing Address - Phone:904-321-0121
Mailing Address - Fax:
Practice Address - Street 1:501 CENTRE ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3936
Practice Address - Country:US
Practice Address - Phone:904-321-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6172103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75324OtherBXBS - FL
FLU4448Medicare ID - Type Unspecified