Provider Demographics
NPI:1770144669
Name:BAKER, DUSTIN FORREST (PHD)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:FORREST
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 1:2130 GRAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5384
Mailing Address - Country:US
Mailing Address - Phone:515-270-0280
Mailing Address - Fax:515-270-1647
Practice Address - Street 1:2130 GRAND AVE STE B
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-5384
Practice Address - Country:US
Practice Address - Phone:515-270-0280
Practice Address - Fax:515-270-1647
Is Sole Proprietor?:No
Enumeration Date:2019-06-22
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018043003103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling