Healthcare Provider Details

I. General information

NPI: 1811520745
Provider Name (Legal Business Name): MARY ROXANNE BAKER MS, LMHCA, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ROXANNE HACKETT

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 E JACKSON BLVD
ELKHART IN
46516-4351
US

IV. Provider business mailing address

926 E JACKSON BLVD
ELKHART IN
46516-4351
US

V. Phone/Fax

Practice location:
  • Phone: 574-575-6557
  • Fax: 574-522-0481
Mailing address:
  • Phone: 574-522-6292
  • Fax: 574-522-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number99097331A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number88001264A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number309005026A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: