MEDICARE: LUCAS DAVID BAKER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	13901326-2501	UT

General Provider Information

NPI Number	:	1881442739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUCAS DAVID BAKER PHD

Provider Business Mailing Address
First Line	:	2150 S MCCLELLAND ST APT 239
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-6206
Country	:	US
Telephone Number	:	307-262-2808
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 S MCCLELLAND ST APT 239
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-6206
Country	:	US
Telephone Number	:	307-262-2808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2024
Last Update Date	:	05/07/2024

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