MEDICARE: MS. MARY LOUISE BAKER LCSW

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	1041C0700X	Clinical Social Worker	0904006480	VA

General Provider Information

NPI Number	:	1548484603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LOUISE BAKER LCSW

Provider Business Mailing Address
First Line	:	505 WASHINGTON ST
Second Line	:	SUITE 501
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-3504
Country	:	US
Telephone Number	:	757-393-5404
Fax Number	:	757-393-5405

Provider Business Practice Location Address
First Line	:	505 WASHINGTON ST
Second Line	:	SUITE 501
City	:	PORTSMOUTH
State	:	VA
Zip	:	23704-3504
Country	:	US
Telephone Number	:	757-393-5404
Fax Number	:	757-393-5405

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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