Provider Demographics
NPI:1861786436
Name:BAKER, BRENDA LOU (LCSW,LADAC)
Entity type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:LOU
Last Name:BAKER
Suffix:
Gender:F
Credentials:LCSW,LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 W BOONE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-6813
Mailing Address - Country:US
Mailing Address - Phone:479-409-1400
Mailing Address - Fax:479-301-2305
Practice Address - Street 1:4210 N FRONTAGE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5001
Practice Address - Country:US
Practice Address - Phone:479-409-1400
Practice Address - Fax:479-301-2305
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1765-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical