Provider Demographics
NPI:1609581420
Name:BAKER, SHATIA
Entity type:Individual
Prefix:
First Name:SHATIA
Middle Name:
Last Name:BAKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3288 GRAMERCY PL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0580
Mailing Address - Country:US
Mailing Address - Phone:850-559-5641
Mailing Address - Fax:
Practice Address - Street 1:1112 THOMASVILLE RD STE 5
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6534
Practice Address - Country:US
Practice Address - Phone:850-559-5641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH21580101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty