Healthcare Provider Details

I. General information

NPI: 1023775673
Provider Name (Legal Business Name): Kathleen Rose Baker Pre-Licensed Clinician
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: Katy

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 NEW ST APT 304
PHILADELPHIA PA
19106-1134
US

IV. Provider business mailing address

315 NEW ST APT 304
PHILADELPHIA PA
19106-1134
US

V. Phone/Fax

Practice location:
  • Phone: 484-800-1001
  • Fax:
Mailing address:
  • Phone: 484-800-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: