MEDICARE: GARY R BAKER JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1487109302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY R BAKER JR.

Provider Business Mailing Address
First Line	:	8915 SW CENTER ST
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-6307
Country	:	US
Telephone Number	:	503-726-3740
Fax Number	:

Provider Business Practice Location Address
First Line	:	3624 SE 40TH AVE APT 26
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97202-1777
Country	:	US
Telephone Number	:	707-782-6561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2016
Last Update Date	:	08/20/2016

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