Provider Demographics
NPI:1518526979
Name:BAKER, DANIELLESHERRI WANDA (171M00000X)
Entity type:Individual
Prefix:
First Name:DANIELLESHERRI
Middle Name:WANDA
Last Name:BAKER
Suffix:
Gender:F
Credentials:171M00000X
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 DONNELLY PL
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5506
Mailing Address - Country:US
Mailing Address - Phone:916-796-2823
Mailing Address - Fax:
Practice Address - Street 1:555 W GRANADA BLVD STE A11
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9488
Practice Address - Country:US
Practice Address - Phone:916-796-2823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-238468106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician