Provider Demographics
NPI:1497122816
Name:BAKER, CARLY JEAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
Last Name:BAKER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JEAN
Other - Last Name:RUSCHEINSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1936 N. 11TH ST.
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1914
Mailing Address - Country:US
Mailing Address - Phone:701-258-0029
Mailing Address - Fax:701-258-0826
Practice Address - Street 1:1936 N. 11TH ST.
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1914
Practice Address - Country:US
Practice Address - Phone:701-258-0029
Practice Address - Fax:701-258-0826
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2255A2300X
ND2278208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer