MEDICARE: KENNISE J BAKER LMSW

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	101YM0800X	Mental Health Counselor	0903003470	VA

General Provider Information

NPI Number	:	1972205425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNISE J BAKER LMSW

Provider Business Mailing Address
First Line	:	11415 ISAAC NEWTON SQ S
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20190-5005
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2343 DULLES STATION BLVD APT B04
Second Line	:
City	:	HERNDON
State	:	VA
Zip	:	20171-6397
Country	:	US
Telephone Number	:	571-241-9834
Fax Number	:

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

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	03/23/2023

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