MEDICARE: MS. CORLISS MARGARET BACA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	10653	CA

General Provider Information

NPI Number	:	1083781421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CORLISS MARGARET BACA LCSW

Provider Business Mailing Address
First Line	:	1575 SUNSET CLIFFS BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-3433
Country	:	US
Telephone Number	:	619-222-0048
Fax Number	:	858-541-5244

Provider Business Practice Location Address
First Line	:	2901 MEADOW LARK DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2711
Country	:	US
Telephone Number	:	858-541-5244
Fax Number	:	858-541-5221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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