Healthcare Provider Details

I. General information

NPI: 1760907091
Provider Name (Legal Business Name): MICAH BAKER LPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S RAINBOW RD
ROGERS AR
72758
US

IV. Provider business mailing address

1601 S RAINBOW RD
ROGERS AR
72758-8821
US

V. Phone/Fax

Practice location:
  • Phone: 479-254-1144
  • Fax: 479-254-1144
Mailing address:
  • Phone: 479-254-1144
  • Fax: 479-254-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number13-30EI
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: