Provider Demographics
NPI:1134305733
Name:MARK BAKER, PHD
Entity Type:Organization
Organization Name:MARK BAKER, PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:626-351-9616
Mailing Address - Street 1:650 SIERRA MADRE VILLA AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2013
Mailing Address - Country:US
Mailing Address - Phone:626-351-9616
Mailing Address - Fax:626-351-9493
Practice Address - Street 1:650 SIERRA MADRE VILLA AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-2013
Practice Address - Country:US
Practice Address - Phone:626-351-9616
Practice Address - Fax:626-351-9493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9219103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP9219AMedicare PIN