Provider Demographics
NPI:1730404633
Name:BAKER, BRENDA JEANNE (MA, BCBA, LMT)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:JEANNE
Last Name:BAKER
Suffix:
Gender:F
Credentials:MA, BCBA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:804 MOHAWK PKWY APT 104
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5750
Mailing Address - Country:US
Mailing Address - Phone:239-784-3741
Mailing Address - Fax:239-236-1718
Practice Address - Street 1:804 MOHAWK PKWY APT 104
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-5750
Practice Address - Country:US
Practice Address - Phone:239-784-3741
Practice Address - Fax:239-236-1718
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-02
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-09-5040103K00000X
FLMA 57488225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist