Basic Information
| Provider Information | |||||||||
| NPI: | 1851904379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | VARRENZA | ||||||||
| MiddleName: | LASHAUN | ||||||||
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| Credential: | CTRS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 174 SHOAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302525822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563906779 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 HARDEE AVE SW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303105110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225800000X | 82164 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Recreation Therapist |
No ID Information.