Provider Demographics
NPI:1306366521
Name:BAKER, MALLARY
Entity Type:Individual
Prefix:
First Name:MALLARY
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 WESTERN GALES DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-9197
Mailing Address - Country:US
Mailing Address - Phone:870-316-0789
Mailing Address - Fax:
Practice Address - Street 1:1699 RED WOLF BLVD STE H
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5453
Practice Address - Country:US
Practice Address - Phone:870-336-0021
Practice Address - Fax:870-336-0021
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR17-0072355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARSLPAOtherSPEECH ASSISTANT