Healthcare Provider Details

I. General information

NPI: 1871091074
Provider Name (Legal Business Name): KRYSTLE DIONNA GRAHAM BAKER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 COMMERCE AVE
CHESTERFIELD SC
29709
US

IV. Provider business mailing address

P.O. BOX 918
BENNETTSVILLE SC
29512
US

V. Phone/Fax

Practice location:
  • Phone: 843-623-2229
  • Fax:
Mailing address:
  • Phone: 843-544-4098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: