Basic Information
| Provider Information | |||||||||
| NPI: | 1720501927 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BAKER | ||||||||
| FirstName: | BRE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1937 S 400 W | ||||||||
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| City: | RUSSIAVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469799137 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2701 CHESTNUT STATION CT | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402996395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003351060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2017 | ||||||||
| LastUpdateDate: | 07/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.