Healthcare Provider Details

I. General information

NPI: 1437524766
Provider Name (Legal Business Name): JOSHUA BACA MA, MPA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 01/22/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5312 JAGUAR DR
SANTA FE NM
87507-1827
US

IV. Provider business mailing address

5312 JAGUAR DR
SANTA FE NM
87507-1827
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-4985
  • Fax: 505-471-6084
Mailing address:
  • Phone: 505-471-4985
  • Fax: 505-471-6084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0215181
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: