Basic Information
| Provider Information | |||||||||
| NPI: | 1083907984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | TOSHA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUNLAP | ||||||||
| OtherFirstName: | TOSHA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | COTA/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10101 MADDOX LN | ||||||||
| Address2: | E 102 | ||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341357641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189256092 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26850 S BAY DR | ||||||||
| Address2: | |||||||||
| City: | BONITA SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341344379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399482600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 05/25/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | OTA10267 | FL | Y | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |
No ID Information.