Provider Demographics
NPI:1043941610
Name:BAKER, DUSTIN KYLE (COTA/L)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:KYLE
Last Name:BAKER
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 ELDERBERRY ST
Mailing Address - Street 2:
Mailing Address - City:PELL CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35128-7345
Mailing Address - Country:US
Mailing Address - Phone:205-516-2842
Mailing Address - Fax:
Practice Address - Street 1:622-692 10TH ST SW
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211
Practice Address - Country:US
Practice Address - Phone:205-783-3292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5746224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant