Provider Demographics
NPI:1891415105
Name:BAKER, EDWARD ZHAO DA
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ZHAO DA
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11122 E LAKESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47872-8034
Mailing Address - Country:US
Mailing Address - Phone:317-540-5094
Mailing Address - Fax:
Practice Address - Street 1:7105 GALEN DR W
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8450
Practice Address - Country:US
Practice Address - Phone:317-813-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-21-178302106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician