MEDICARE: LISA R BAKER LCMS, BC-TMH

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	6801087395	MI

General Provider Information

NPI Number	:	1962988030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA R BAKER LCMS, BC-TMH

Provider Business Mailing Address
First Line	:	5085 SUNNY CREEK CT SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-4972
Country	:	US
Telephone Number	:	616-443-3853
Fax Number	:

Provider Business Practice Location Address
First Line	:	1115 ALTO AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49507-1403
Country	:	US
Telephone Number	:	616-443-3853
Fax Number	:

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

Provider Enumeration Date	:	07/12/2018
Last Update Date	:	07/12/2018

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