Provider Demographics
NPI:1346767506
Name:BAKER, KELLY (LMSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4230
Mailing Address - Country:US
Mailing Address - Phone:810-300-9619
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-985-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011076581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical