Provider Demographics
NPI:1811520745
Name:BAKER, MARY ROXANNE (MS, LMHCA, NCC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ROXANNE
Last Name:BAKER
Suffix:
Gender:F
Credentials:MS, LMHCA, NCC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ROXANNE
Other - Last Name:HACKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:926 E JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4351
Mailing Address - Country:US
Mailing Address - Phone:574-522-6292
Mailing Address - Fax:574-522-0481
Practice Address - Street 1:926 E JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4351
Practice Address - Country:US
Practice Address - Phone:574-575-6557
Practice Address - Fax:574-522-0481
Is Sole Proprietor?:No
Enumeration Date:2020-02-19
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99097331A101Y00000X
IN88001264A101Y00000X
IN309005026A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor