Provider Demographics
NPI:1275836769
Name:BAKER, MARTHA LESLIE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LESLIE
Last Name:BAKER
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 MOUNTAIN CREST DR
Mailing Address - Street 2:
Mailing Address - City:CLARKESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30523-2931
Mailing Address - Country:US
Mailing Address - Phone:706-969-8542
Mailing Address - Fax:
Practice Address - Street 1:121 OLD DAWSON VILLAGE RD E
Practice Address - Street 2:BUILDING 800, UNIT 010
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534
Practice Address - Country:US
Practice Address - Phone:706-265-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006234101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional