Provider Demographics
NPI:1609903186
Name:BAKER, LYDA A (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:LYDA
Middle Name:A
Last Name:BAKER
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 W NORTHERN LIGHTS BLVD # 830
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2337
Mailing Address - Country:US
Mailing Address - Phone:907-884-6604
Mailing Address - Fax:
Practice Address - Street 1:951 W SELDON RD APT 3
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-3464
Practice Address - Country:US
Practice Address - Phone:907-884-6604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2002225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00071986Medicaid
AK2002OtherOT LISCENSE