Healthcare Provider Details

I. General information

NPI: 1053818823
Provider Name (Legal Business Name): TREVOR BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 CULEBRA RD
SAN ANTONIO TX
78228-5914
US

IV. Provider business mailing address

4807 HEATHER PASS
SAN ANTONIO TX
78218-2748
US

V. Phone/Fax

Practice location:
  • Phone: 210-314-6473
  • Fax:
Mailing address:
  • Phone: 254-466-9030
  • 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: