Provider Demographics
NPI:1982969465
Name:BAKER VICTORY
Entity Type:Organization
Organization Name:BAKER VICTORY
Other - Org Name:CHILDPRO
Other - Org Type:Other Name
Authorized Official - Title/Position:SPECIAL EDUCATION THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:POVINELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-909-5662
Mailing Address - Street 1:697 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1500
Mailing Address - Country:US
Mailing Address - Phone:716-822-4781
Mailing Address - Fax:716-825-5765
Practice Address - Street 1:697 RIDGE RD
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1500
Practice Address - Country:US
Practice Address - Phone:716-822-4781
Practice Address - Fax:716-825-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1127815252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency