Healthcare Provider Details

I. General information

NPI: 1043650724
Provider Name (Legal Business Name): MRS. EBONY M BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. EBONY M BAKER

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 03/11/2023
Certification Date: 03/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1172 3RD AVE STE D-1
CHULA VISTA CA
91911-3116
US

IV. Provider business mailing address

16611 QUAIL PARK DR
MISSOURI CITY TX
77489-5305
US

V. Phone/Fax

Practice location:
  • Phone: 619-691-1662
  • Fax:
Mailing address:
  • Phone: 281-573-7247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: