Basic Information
| Provider Information | |||||||||
| NPI: | 1164067229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2945 MCMILLAN AVE STE 240 | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934016771 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5205 CASCABEL RD | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934222316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054394890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2019 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 41105 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.