Provider Demographics
NPI:1073822789
Name:RUSSACK-BAKER, LEAH AV (LADC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:AV
Last Name:RUSSACK-BAKER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:AV
Other - Last Name:RUSSACK-BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LADC
Mailing Address - Street 1:123 ELM ST
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4108
Mailing Address - Country:US
Mailing Address - Phone:860-395-1264
Mailing Address - Fax:
Practice Address - Street 1:123 ELM ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475
Practice Address - Country:US
Practice Address - Phone:860-395-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT03-973340101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1730336439Medicaid