Provider Demographics
NPI:1053308528
Name:BAKER, MONTY TIMOTHY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MONTY
Middle Name:TIMOTHY
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2200 BERGQUIST DR
Mailing Address - Street 2:STE. 1, LIFE SKILLS SUPPORT CENTER, 59 MDOS MMCM
Mailing Address - City:LACKLAND A F B
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9907
Mailing Address - Country:US
Mailing Address - Phone:210-292-7361
Mailing Address - Fax:210-292-2520
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:STE. 1, LIFE SKILLS SUPPORT CENTER, 59 MDOS MMCM
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-7361
Practice Address - Fax:210-292-2520
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPY 7200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical