Provider Demographics
NPI:1770780579
Name:BAKER, KRISTY R (PSYD)
Entity type:Individual
Prefix:DR
First Name:KRISTY
Middle Name:R
Last Name:BAKER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22809 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-6202
Mailing Address - Country:US
Mailing Address - Phone:503-449-9595
Mailing Address - Fax:
Practice Address - Street 1:516 SE MORRISON ST
Practice Address - Street 2:SUITE 650
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2327
Practice Address - Country:US
Practice Address - Phone:503-449-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1747103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical