Healthcare Provider Details

I. General information

NPI: 1164905709
Provider Name (Legal Business Name): GARY LEE BAKER LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

IV. Provider business mailing address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 440-578-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701003834
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2002236-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: