Provider Demographics
NPI:1669178729
Name:BAKER, BENJAMIN BRYCE
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:BRYCE
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 1:424 REHNBERG PL
Mailing Address - Street 2:
Mailing Address - City:WEST SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1619 DAYTON AVE STE 309
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6276
Practice Address - Country:US
Practice Address - Phone:515-480-8396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4240106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist