Provider Demographics
NPI:1356634067
Name:BAKER, ILENE (LISAC)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 E FORT LOWELL RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2374
Mailing Address - Country:US
Mailing Address - Phone:520-327-4505
Mailing Address - Fax:520-202-1889
Practice Address - Street 1:1650 E FORT LOWELL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2374
Practice Address - Country:US
Practice Address - Phone:520-327-4505
Practice Address - Fax:520-202-1889
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10560101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)