Provider Demographics
NPI:1568248813
Name:BAKER JR, LEON
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:BAKER JR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313-329 15TH AVE APT 217
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-5611
Mailing Address - Country:US
Mailing Address - Phone:862-276-9176
Mailing Address - Fax:
Practice Address - Street 1:626 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-3206
Practice Address - Country:US
Practice Address - Phone:201-372-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00409100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant