Provider Demographics
NPI:1770225112
Name:BAKE, PRISCILLA SHARON-GEORGIA (LMSW)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:SHARON-GEORGIA
Last Name:BAKE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 FRANKLIN AVE APT B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3175
Mailing Address - Country:US
Mailing Address - Phone:208-241-7546
Mailing Address - Fax:
Practice Address - Street 1:109 N ARTHUR AVE STE 203
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3105
Practice Address - Country:US
Practice Address - Phone:208-234-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-42222101YM0800X, 104100000X
IDLSW-40865104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker