Provider Demographics
NPI:1205002680
Name:BAKER, DAVID WAYNE (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 BERRYWOOD DR
Mailing Address - Street 2:200
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3407 BERRYWOOD DR
Practice Address - Street 2:200
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6500
Practice Address - Country:US
Practice Address - Phone:573-443-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007033943103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool