Healthcare Provider Details

I. General information

NPI: 1114411170
Provider Name (Legal Business Name): KELSIE NICOLE BACON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 RIO GRANDE BLVD NW
ALBUQUERQUE NM
87104-2529
US

IV. Provider business mailing address

307 PRINCETON DR SE APT C
ALBUQUERQUE NM
87106-2898
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-1871
  • Fax:
Mailing address:
  • Phone: 505-903-2098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX-10527
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: