Provider Demographics
NPI:1699269316
Name:BAKER, SHANA MONIQUE
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:MONIQUE
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 1:23222 GERALDINE CT
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3551
Mailing Address - Country:US
Mailing Address - Phone:510-331-4635
Mailing Address - Fax:
Practice Address - Street 1:614 GRAND AVE STE 203
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-3554
Practice Address - Country:US
Practice Address - Phone:510-433-0244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-16
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT121877106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist