Provider Demographics
NPI:1407109853
Name:BAKER, KACY L (MSW)
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:L
Last Name:BAKER
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2789 ORTIZ AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7806
Mailing Address - Country:US
Mailing Address - Phone:239-275-3222
Mailing Address - Fax:239-278-9058
Practice Address - Street 1:2789 ORTIZ AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7806
Practice Address - Country:US
Practice Address - Phone:239-275-3222
Practice Address - Fax:239-278-9058
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW130331041C0700X
FLB260512878050171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB260512878050OtherDRIVERS LICENSE