Healthcare Provider Details

I. General information

NPI: 1083170930
Provider Name (Legal Business Name): ALYSSA LENAE BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2019
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 E HACKETT RD
MODESTO CA
95358-9001
US

IV. Provider business mailing address

190 E HACKETT RD
MODESTO CA
95358-9001
US

V. Phone/Fax

Practice location:
  • Phone: 209-505-4765
  • Fax: 209-558-1025
Mailing address:
  • Phone: 209-505-4765
  • Fax: 209-558-1025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: