Provider Demographics
NPI:1679030993
Name:BAKER, KOURTNEY MICHELLE
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:MICHELLE
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 SAN MARIE DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2351
Mailing Address - Country:US
Mailing Address - Phone:904-719-0836
Mailing Address - Fax:
Practice Address - Street 1:5150 PALM VALLEY RD STE 102
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4630
Practice Address - Country:US
Practice Address - Phone:904-719-0836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-72277106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician