Provider Demographics
NPI:1508270752
Name:BAKER, TRACI (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-4415
Mailing Address - Country:US
Mailing Address - Phone:573-472-2139
Mailing Address - Fax:
Practice Address - Street 1:903 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-4415
Practice Address - Country:US
Practice Address - Phone:573-472-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120369781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical