Provider Demographics
NPI:1962919720
Name:BAKER, AUSTIN DAVID
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:DAVID
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 1:1863 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-6904
Mailing Address - Country:US
Mailing Address - Phone:720-951-5645
Mailing Address - Fax:
Practice Address - Street 1:1863 10TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-6904
Practice Address - Country:US
Practice Address - Phone:720-951-5645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11-074-0588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO$$$$$$$$$OtherN/A