Provider Demographics
NPI:1265747414
Name:BAKER, MARYCAROL (PT, CKTP, CCI)
Entity type:Individual
Prefix:
First Name:MARYCAROL
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:PT, CKTP, CCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1556 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2528
Mailing Address - Country:US
Mailing Address - Phone:314-541-7902
Mailing Address - Fax:
Practice Address - Street 1:210 FERRY WAY
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-1389
Practice Address - Country:US
Practice Address - Phone:314-541-7902
Practice Address - Fax:573-803-0742
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004025487225100000X
AK2398225100000X
IDRPT-344225100000X
IL070003083225100000X
NCP13507225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist