Provider Demographics
NPI:1043943558
Name:BAKER, CANAAN (MA, LCDC)
Entity Type:Individual
Prefix:
First Name:CANAAN
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:MA, LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 ADLETA BLVD APT 2012
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-9263
Mailing Address - Country:US
Mailing Address - Phone:904-422-7752
Mailing Address - Fax:
Practice Address - Street 1:4600 GREENVILLE AVE STE 252
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-5037
Practice Address - Country:US
Practice Address - Phone:214-618-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-03
Last Update Date:2022-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15754101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)