Healthcare Provider Details

I. General information

NPI: 1891457008
Provider Name (Legal Business Name): MR. JOHN PAUL BACA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16650 SHERMAN WAY
VAN NUYS CA
91406-3782
US

IV. Provider business mailing address

15228 NURMI ST
SYLMAR CA
91342-3719
US

V. Phone/Fax

Practice location:
  • Phone: 818-901-4836
  • Fax:
Mailing address:
  • Phone: 818-792-3539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: