Healthcare Provider Details

I. General information

NPI: 1689031221
Provider Name (Legal Business Name): COURTNEY BAKER LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 FOGG FARM ROAD
WILDER VT
05088
US

IV. Provider business mailing address

PO BOX G
RANDOLPH VT
05060-0167
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-1311
  • Fax: 802-295-1312
Mailing address:
  • Phone: 802-728-4466
  • Fax: 802-428-4197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number000702
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: