Provider Demographics
NPI:1497511364
Name:BAKER, KEITH LEVEQ (PLPC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:LEVEQ
Last Name:BAKER
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22015 HALLIBURTON CV
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-7357
Mailing Address - Country:US
Mailing Address - Phone:225-505-9630
Mailing Address - Fax:
Practice Address - Street 1:5740 GETWELL RD STE D
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6346
Practice Address - Country:US
Practice Address - Phone:601-790-0583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP-1069101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor