Provider Demographics
NPI:1730554916
Name:BAKER, ANTONIO
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:BAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 FARMERVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-3513
Mailing Address - Country:US
Mailing Address - Phone:318-224-7017
Mailing Address - Fax:318-224-7018
Practice Address - Street 1:1231 FARMERVILLE HWY
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3513
Practice Address - Country:US
Practice Address - Phone:318-224-7017
Practice Address - Fax:318-224-7018
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009022335101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health