Provider Demographics
NPI:1962677492
Name:BAKER, BRENDA K (LISW)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:K
Last Name:BAKER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 ROAD 3953
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7990
Mailing Address - Country:US
Mailing Address - Phone:505-486-9942
Mailing Address - Fax:
Practice Address - Street 1:19 ROAD 3953
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7990
Practice Address - Country:US
Practice Address - Phone:505-486-9942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-06619104100000X
NMI-073041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28005775Medicaid