Provider Demographics
NPI:1881456051
Name:BAKER, MARSHALL JR
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:BAKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3920 BAMBERG LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6048
Mailing Address - Country:US
Mailing Address - Phone:682-223-5893
Mailing Address - Fax:
Practice Address - Street 1:3920 BAMBERG LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6048
Practice Address - Country:US
Practice Address - Phone:682-233-5893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205344103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling