Provider Demographics
NPI:1255813531
Name:BAKER, QUANTRELL
Entity type:Individual
Prefix:
First Name:QUANTRELL
Middle Name:
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 1:3358 CANDELARIA DR
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-1705
Mailing Address - Country:US
Mailing Address - Phone:775-409-2146
Mailing Address - Fax:
Practice Address - Street 1:3358 CANDELARIA DR
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-1705
Practice Address - Country:US
Practice Address - Phone:775-409-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV83-1777937Medicaid
NV83-1777937Medicaid