Provider Demographics
NPI:1730161001
Name:BAKER, ROSALYN (LMSW LMFT)
Entity type:Individual
Prefix:MRS
First Name:ROSALYN
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMSW LMFT
Other - Prefix:MRS
Other - First Name:ROSALYN
Other - Middle Name:
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW LMFT
Mailing Address - Street 1:PO BOX 1767
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1767
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:3368 E BELTLINE CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9480
Practice Address - Country:US
Practice Address - Phone:616-236-3637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801018347104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0890130Medicare PIN