Provider Demographics
NPI:1538169610
Name:BAKER, JUDITH ANN (LISW)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:BAKER
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:261 CAMINO DEL OLMO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2377
Mailing Address - Country:US
Mailing Address - Phone:505-946-8155
Mailing Address - Fax:
Practice Address - Street 1:901 W SAN MATEO RD
Practice Address - Street 2:SUITE #D-4
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3981
Practice Address - Country:US
Practice Address - Phone:505-946-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-050921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM71606556Medicaid