Provider Demographics
NPI:1841353604
Name:GRIDER-BAKER, TERESA MARIE (LISW)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIE
Last Name:GRIDER-BAKER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 PROSPECT CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9128
Mailing Address - Country:US
Mailing Address - Phone:319-365-9164
Mailing Address - Fax:319-368-3358
Practice Address - Street 1:2309 C ST SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-3707
Practice Address - Country:US
Practice Address - Phone:319-365-9164
Practice Address - Fax:319-368-3358
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA058191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA38246OtherWELLMARK
IA246645OtherMIDLAND'S CHOICE