Provider Demographics
NPI:1245391549
Name:BAKER, BRAD (PHD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
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:PO BOX 3480
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3480
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:2235 E 25TH ST STE 290
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7595
Practice Address - Country:US
Practice Address - Phone:208-552-0490
Practice Address - Fax:208-552-2518
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3192101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806472900Medicaid