Provider Demographics
NPI:1497194161
Name:BAKER, AUSTIN CLAY (LMT, MMP)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CLAY
Last Name:BAKER
Suffix:
Gender:M
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 FLORIDA NATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1515
Mailing Address - Country:US
Mailing Address - Phone:863-644-7838
Mailing Address - Fax:863-644-7805
Practice Address - Street 1:4414 FLORIDA NATIONAL DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1515
Practice Address - Country:US
Practice Address - Phone:863-644-7838
Practice Address - Fax:863-644-7805
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68362225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC10QBOtherFLORIDA BLUE