Healthcare Provider Details

I. General information

NPI: 1346594447
Provider Name (Legal Business Name): GLENN BAKER MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GLENN BAKER MFT

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22287 MULHOLLAND HWY # 136
CALABASAS CA
91302-5157
US

IV. Provider business mailing address

5756 MELROSE AVE
LOS ANGELES CA
90038-3845
US

V. Phone/Fax

Practice location:
  • Phone: 818-635-9380
  • Fax:
Mailing address:
  • Phone: 818-635-9380
  • Fax: 818-337-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number38162
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: