Provider Demographics
NPI:1700030962
Name:BAKER, URSULA PAULA (BS; LISAC)
Entity Type:Individual
Prefix:MS
First Name:URSULA
Middle Name:PAULA
Last Name:BAKER
Suffix:
Gender:F
Credentials:BS; LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3005
Mailing Address - Country:US
Mailing Address - Phone:928-289-2650
Mailing Address - Fax:928-289-0477
Practice Address - Street 1:1301 W SECOND ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3005
Practice Address - Country:US
Practice Address - Phone:928-289-2650
Practice Address - Fax:928-289-0477
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162282OtherAHCCCS