Provider Demographics
NPI:1629717376
Name:BAKER, MINDY LYNN
Entity Type:Individual
Prefix:MS
First Name:MINDY
Middle Name:LYNN
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IP
Mailing Address - Street 1:898 ABIGAIL CT
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-3500
Mailing Address - Country:US
Mailing Address - Phone:208-206-7840
Mailing Address - Fax:
Practice Address - Street 1:898 ABIGAIL CT
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-3500
Practice Address - Country:US
Practice Address - Phone:208-206-7840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID106S00000XMedicaid