Provider Demographics
NPI:1396287322
Name:BAKER, LUSTER
Entity type:Individual
Prefix:
First Name:LUSTER
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 DEBRA ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3319
Mailing Address - Country:US
Mailing Address - Phone:318-676-8096
Mailing Address - Fax:
Practice Address - Street 1:1513 DEBRA ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3319
Practice Address - Country:US
Practice Address - Phone:318-676-8096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA007443587OtherDRIVERS LICENSE