Provider Demographics
NPI:1164739934
Name:CARLY BAKER
Entity Type:Organization
Organization Name:CARLY BAKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-792-2646
Mailing Address - Street 1:146 TILSON ST E
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:WI
Mailing Address - Zip Code:54669-1213
Mailing Address - Country:US
Mailing Address - Phone:608-792-2646
Mailing Address - Fax:
Practice Address - Street 1:146 E TILSON ST.
Practice Address - Street 2:
Practice Address - City:WEST SALEM
Practice Address - State:WI
Practice Address - Zip Code:54669-1213
Practice Address - Country:US
Practice Address - Phone:608-792-2646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302971-031385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child