Provider Demographics
NPI:1881407898
Name:BAKER, SHANNON R
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:R
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 N MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3106
Mailing Address - Country:US
Mailing Address - Phone:937-277-9371
Mailing Address - Fax:937-277-7734
Practice Address - Street 1:5900 N MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3106
Practice Address - Country:US
Practice Address - Phone:937-277-9371
Practice Address - Fax:937-277-7734
Is Sole Proprietor?:No
Enumeration Date:2025-01-31
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2406362101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional