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General NPI Number Information
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NPI Number | 1104033109
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Entity Type | Individual
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Provider Name | RONALD A. BACON M.A., M.DIV.
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Gender | Male
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Dates
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Enumeration Date | 05/17/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 31952 CAMINO CAPISTRANO C-23
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City | SAN JUAN CAPISTRANO
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State | CA
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Zip | 92675-3229
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Country | US
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Telephone | 949-488-8990
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Fax | 949-488-9550
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Provider Business Mailing Address
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Address Line | 31952 CAMINO CAPISTRANO C-23
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City | SAN JUAN CAPISTRANO
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State | CA
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Zip | 92675-3229
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Country | US
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Telephone | 949-488-8990
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Fax | 949-488-9550
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC 28250
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License Number State | CA
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