Provider Demographics
NPI:1871962100
Name:BAKER, RANDOLPH TERRY (LMT)
Entity type:Individual
Prefix:MR
First Name:RANDOLPH
Middle Name:TERRY
Last Name:BAKER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3461 LAWRENCEVILLE SUWANEE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6428
Mailing Address - Country:US
Mailing Address - Phone:815-262-8563
Mailing Address - Fax:
Practice Address - Street 1:3461 LAWRENCEVILLE SUWANEE RD
Practice Address - Street 2:SUITE B
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6428
Practice Address - Country:US
Practice Address - Phone:815-262-8563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010074225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist