Provider Demographics
NPI:1962988030
Name:BAKER, LISA R (LCMS, BC-TMH)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:BAKER
Suffix:
Gender:F
Credentials:LCMS, BC-TMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5085 SUNNY CREEK CT SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4972
Mailing Address - Country:US
Mailing Address - Phone:616-443-3853
Mailing Address - Fax:
Practice Address - Street 1:1115 ALTO AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1403
Practice Address - Country:US
Practice Address - Phone:616-443-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010873951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty