Provider Demographics
NPI:1588440176
Name:BAKER, MADISON L
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:L
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 1:4178 KANSAS ST APT 11
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1830
Mailing Address - Country:US
Mailing Address - Phone:818-792-1845
Mailing Address - Fax:
Practice Address - Street 1:3878 RUFFIN RD STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1842
Practice Address - Country:US
Practice Address - Phone:619-795-9925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician