Provider Demographics
NPI:1174707079
Name:BAKER, THOMAS DALE (PHD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DALE
Last Name:BAKER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 101092
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33910-1092
Mailing Address - Country:US
Mailing Address - Phone:239-297-5725
Mailing Address - Fax:
Practice Address - Street 1:1639 CAPE CORAL PKWY E
Practice Address - Street 2:207
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9651
Practice Address - Country:US
Practice Address - Phone:239-297-5725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0005090103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical