MEDICARE: DR. SANDRA G BACA LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	M24284	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M24284	OTHER	CA	BOARD BEHAVIORAL EXAMINER

General Provider Information

NPI Number	:	1043312069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANDRA G BACA LMFT

Provider Business Mailing Address
First Line	:	25410 LONGFELLOW PL
Second Line	:
City	:	STEVENSON RANCH
State	:	CA
Zip	:	91381
Country	:	US
Telephone Number	:	661-255-6454
Fax Number	:	661-255-2709

Provider Business Practice Location Address
First Line	:	3407 W 6TH ST
Second Line	:	STE 700
City	:	LOS ANGELES
State	:	CA
Zip	:	90020
Country	:	US
Telephone Number	:	213-384-7084
Fax Number	:	213-384-5673

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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