Healthcare Provider Details

I. General information

NPI: 1912138835
Provider Name (Legal Business Name): CRESTON ZANE BAKER LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 MACK AVE STE B
FREDERICK MD
21703-3303
US

IV. Provider business mailing address

13121 BROOKLANE DR
HAGERSTOWN MD
21742-1514
US

V. Phone/Fax

Practice location:
  • Phone: 301-733-0330
  • Fax: 301-733-4038
Mailing address:
  • Phone: 301-733-0330
  • Fax: 301-733-4038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC1532
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLC1532
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: