Healthcare Provider Details

I. General information

NPI: 1104602663
Provider Name (Legal Business Name): LUKE PATRICK BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8609 W BRYN MAWR AVE STE 204
CHICAGO IL
60631-3524
US

IV. Provider business mailing address

7107 104TH AVE UNIT P
KENOSHA WI
53142-7889
US

V. Phone/Fax

Practice location:
  • Phone: 773-644-7787
  • Fax:
Mailing address:
  • Phone: 224-406-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-23-14719
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: