Provider Demographics
NPI:1083957419
Name:BAKER, BREANNE MICHELLE
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:MICHELLE
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7491 W MISSION VIEW PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-5419
Mailing Address - Country:US
Mailing Address - Phone:520-579-0222
Mailing Address - Fax:
Practice Address - Street 1:2708 NE 14TH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-3565
Practice Address - Country:US
Practice Address - Phone:888-880-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZA66060115Medicaid