Provider Demographics
NPI:1659666444
Name:BAKER, SHUKAIRO M (LCSW, LISW-CP, LCAS)
Entity Type:Individual
Prefix:
First Name:SHUKAIRO
Middle Name:M
Last Name:BAKER
Suffix:
Gender:F
Credentials:LCSW, LISW-CP, LCAS
Other - Prefix:
Other - First Name:SHUKAIRO
Other - Middle Name:MACK
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1365 EBENEZER RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2336
Mailing Address - Country:US
Mailing Address - Phone:803-708-7556
Mailing Address - Fax:803-708-7801
Practice Address - Street 1:1365 EBENEZER RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732
Practice Address - Country:US
Practice Address - Phone:803-708-7556
Practice Address - Fax:803-708-7801
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC008389101YA0400X, 1041C0700X
SC110941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1253Medicaid
SCQ554550281OtherPTAN
NC1659666444Medicaid