Provider Demographics
NPI:1366737488
Name:BAKER, MICHELLE ELIZABETH (LMP, NCTMB)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:BAKER
Suffix:
Gender:F
Credentials:LMP, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:GRITMAN MEDICAL CENTER
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-883-6361
Practice Address - Fax:208-883-6452
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60231085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist