Healthcare Provider Details

I. General information

NPI: 1306242474
Provider Name (Legal Business Name): MEREDITH BACA LPCC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 FOG ROAD
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 1045
OHKAY OWINGEH NM
87566-1045
US

V. Phone/Fax

Practice location:
  • Phone: 210-862-1037
  • Fax:
Mailing address:
  • Phone: 210-593-8552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number68716
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH200151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: