Healthcare Provider Details

I. General information

NPI: 1427236371
Provider Name (Legal Business Name): SANDRA JO BAKER MED LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA JO PETERSON MED LPC

II. Dates (important events)

Enumeration Date: 02/02/2008
Last Update Date: 02/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PORT O CALL
AMARILLO TX
79118-9382
US

IV. Provider business mailing address

111 PORT O CALL
AMARILLO TX
79118-9382
US

V. Phone/Fax

Practice location:
  • Phone: 806-622-3672
  • Fax:
Mailing address:
  • Phone: 806-622-3672
  • Fax: 806-354-9596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04437
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: