=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215680673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETHANY BAKER NCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2022
-----------------------------------------------------
Last Update Date | 01/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 W BROAD ST STE 321
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22046-3318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-298-2185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1002 JENNIFER LN
-----------------------------------------------------
City | FALLS CHURCH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22046-2411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-298-2185
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0704013800
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------