Healthcare Provider Details

I. General information

NPI: 1730632456
Provider Name (Legal Business Name): BETHANY BACA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 COLUMBIA DR SE
ALBUQUERQUE NM
87106-3302
US

IV. Provider business mailing address

1636 COLUMBIA DR SE
ALBUQUERQUE NM
87106-3302
US

V. Phone/Fax

Practice location:
  • Phone: 505-907-1583
  • Fax:
Mailing address:
  • Phone: 505-907-1583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number500664169
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: