Provider Demographics
NPI:1497267470
Name:BAKER, TRACIE LYNN (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:LYNN
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15254 N STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-5056
Mailing Address - Country:US
Mailing Address - Phone:208-610-8672
Mailing Address - Fax:
Practice Address - Street 1:7905 N MEADOWLARK WAY STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-5041
Practice Address - Country:US
Practice Address - Phone:208-772-3116
Practice Address - Fax:208-772-3116
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-370931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty