Provider Demographics
NPI:1083136683
Name:KEEGAN BAKER, LCSW, PLLC
Entity Type:Organization
Organization Name:KEEGAN BAKER, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAINE
Authorized Official - Middle Name:KEEGAN
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-833-5677
Mailing Address - Street 1:3 SETALCOTT PL
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1315
Mailing Address - Country:US
Mailing Address - Phone:631-833-5677
Mailing Address - Fax:
Practice Address - Street 1:267 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2874
Practice Address - Country:US
Practice Address - Phone:631-833-5677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0854861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1467727412Medicaid