Healthcare Provider Details

I. General information

NPI: 1083678700
Provider Name (Legal Business Name): BAKER COMMUNITY COUNSELING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 E MACCLENNY AVE
MACCLENNY FL
32063-2121
US

IV. Provider business mailing address

213 E MACCLENNY AVE
MACCLENNY FL
32063-2121
US

V. Phone/Fax

Practice location:
  • Phone: 904-259-0264
  • Fax: 904-259-0265
Mailing address:
  • Phone: 904-259-0264
  • Fax: 904-259-0265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number0402AD048000
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN CHRISTOPHER PADGETT
Title or Position: CLINICAL DIRECTOR
Credential: CAP, ICADC
Phone: 904-259-0264