Provider Demographics
NPI:1881764348
Name:BAKER, EDWIN G (LICSW LADC)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:G
Last Name:BAKER
Suffix:
Gender:M
Credentials:LICSW LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:31 MAIN ST
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0919
Mailing Address - Country:US
Mailing Address - Phone:802-888-3600
Mailing Address - Fax:
Practice Address - Street 1:31 LOWER MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-0919
Practice Address - Country:US
Practice Address - Phone:802-888-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000014101YA0400X
VT08900001611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006728Medicaid