Provider Demographics
NPI:1821717505
Name:BAKER, CODY EVAN (TCADC)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:EVAN
Last Name:BAKER
Suffix:
Gender:M
Credentials:TCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 PEBBLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1848
Mailing Address - Country:US
Mailing Address - Phone:502-260-2806
Mailing Address - Fax:
Practice Address - Street 1:807 PEBBLEBROOK DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1848
Practice Address - Country:US
Practice Address - Phone:502-260-2806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278074101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)