Provider Demographics
NPI:1609976620
Name:BAKER, MARY EILEEN (LPC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:EILEEN
Last Name:BAKER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10605 JUDICIAL DR STE A1
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5116
Mailing Address - Country:US
Mailing Address - Phone:240-350-8696
Mailing Address - Fax:
Practice Address - Street 1:10605 JUDICIAL DR STE A1
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5116
Practice Address - Country:US
Practice Address - Phone:240-350-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2012101YP2500X
VA0701005278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0058157000Medicaid