Provider Demographics
NPI:1346594447
Name:BAKER, GLENN (MFT)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:GLENN
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:5756 MELROSE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3845
Mailing Address - Country:US
Mailing Address - Phone:818-635-9380
Mailing Address - Fax:818-337-0365
Practice Address - Street 1:22287 MULHOLLAND HWY # 136
Practice Address - Street 2:
Practice Address - City:CALABASAS
Practice Address - State:CA
Practice Address - Zip Code:91302-5157
Practice Address - Country:US
Practice Address - Phone:818-635-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38162101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)