Provider Demographics
NPI:1831811397
Name:BAKER, KRISTOPHER W R (LCDC)
Entity type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:W R
Last Name:BAKER
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 PRIVATE ROAD 8179
Mailing Address - Street 2:
Mailing Address - City:EDOM
Mailing Address - State:TX
Mailing Address - Zip Code:75754-5268
Mailing Address - Country:US
Mailing Address - Phone:903-519-6858
Mailing Address - Fax:
Practice Address - Street 1:1510 S VINE AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2826
Practice Address - Country:US
Practice Address - Phone:903-526-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12645101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty