Provider Demographics
NPI:1467187773
Name:BAKER-KULP, MERCEDES (LSW)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:BAKER-KULP
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PENNSYLVANIA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-4427
Mailing Address - Country:US
Mailing Address - Phone:630-474-4353
Mailing Address - Fax:630-790-8898
Practice Address - Street 1:420 PENNSYLVANIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4427
Practice Address - Country:US
Practice Address - Phone:630-474-4353
Practice Address - Fax:630-790-8898
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150105568101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health