Provider Demographics
NPI:1356702781
Name:BAKKE, ANITA C (CLT, LMT)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:C
Last Name:BAKKE
Suffix:
Gender:F
Credentials:CLT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5742 E PERDIDO DR
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-9168
Mailing Address - Country:US
Mailing Address - Phone:623-223-1277
Mailing Address - Fax:
Practice Address - Street 1:34406 N 27TH DR
Practice Address - Street 2:SUITE 140/RM113, BLDG. 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-6082
Practice Address - Country:US
Practice Address - Phone:623-223-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-05867225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist