Basic Information
| Provider Information | |||||||||
| NPI: | 1699975417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | BURDELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W MUHAMMAD ALI BLVD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021423 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 914 E BROADWAY | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402041037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025891100 | ||||||||
| FaxNumber: | 5025898771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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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 | 103T00000X | 130398 | KY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 7100284870 | 05 | KY | MEDICAID |