Healthcare Provider Details

I. General information

NPI: 1073733457
Provider Name (Legal Business Name): LELAND WAYNE BAKER MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLA-OOK-WAH DR
TAHOLAH WA
98587
US

IV. Provider business mailing address

520 LINCOLN ST
HOQUIAM WA
98550
US

V. Phone/Fax

Practice location:
  • Phone: 360-276-4405
  • Fax: 360-276-4474
Mailing address:
  • Phone: 360-276-4405
  • Fax: 360-276-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLW00009203
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: