Provider Demographics
NPI:1972526838
Name:BAKER, RAYMOND CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:CHARLES
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 N PROSPECT RD
Mailing Address - Street 2:SUITE 19A
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-6450
Mailing Address - Country:US
Mailing Address - Phone:309-681-0182
Mailing Address - Fax:309-681-0182
Practice Address - Street 1:4617 N PROSPECT RD
Practice Address - Street 2:SUITE 19A
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-6450
Practice Address - Country:US
Practice Address - Phone:309-681-0182
Practice Address - Fax:309-681-0182
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211103Medicare PIN