Provider Demographics
NPI:1740572635
Name:HENDERSON BAKER, LETICIA TENAYA (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:TENAYA
Last Name:HENDERSON BAKER
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4428 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3405
Mailing Address - Country:US
Mailing Address - Phone:850-482-4177
Mailing Address - Fax:
Practice Address - Street 1:4428 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-3405
Practice Address - Country:US
Practice Address - Phone:850-482-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10207101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)