Healthcare Provider Details

I. General information

NPI: 1356020291
Provider Name (Legal Business Name): MARISA C DE BACA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BERTHA RD
TAOS NM
87571-7148
US

IV. Provider business mailing address

4 SAN FRANCISCO ST UNIT 377
RANCHOS DE TAOS NM
87557-4016
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4297
  • Fax: 575-751-4237
Mailing address:
  • Phone: 575-224-2085
  • Fax: 575-751-4237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2026-0383
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: