Provider Demographics
NPI:1700404456
Name:BAKER, MAC (MSW, CSW, QMHP)
Entity Type:Individual
Prefix:
First Name:MAC
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:MSW, CSW, QMHP
Other - Prefix:
Other - First Name:MACONNELL
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, CSW, QMHP
Mailing Address - Street 1:1520 HAINES AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-0710
Mailing Address - Country:US
Mailing Address - Phone:605-716-7841
Mailing Address - Fax:
Practice Address - Street 1:500 N 5TH ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-1480
Practice Address - Country:US
Practice Address - Phone:605-745-2000
Practice Address - Fax:605-745-2075
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD60971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD041419836054152457Medicaid