Provider Demographics
NPI:1104244052
Name:BAKER, KAYLEE
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
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 1:19 COURT LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:PA
Mailing Address - Zip Code:16930-9207
Mailing Address - Country:US
Mailing Address - Phone:570-404-2982
Mailing Address - Fax:
Practice Address - Street 1:1883 SHUMWAY HILL RD
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-6840
Practice Address - Country:US
Practice Address - Phone:570-724-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP007807224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant