MEDICARE: MONIQUE C BACA LMHC

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	101YM0800X	Mental Health Counselor	T-0151401	NM

General Provider Information

NPI Number	:	1184989675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONIQUE C BACA LMHC

Provider Business Mailing Address
First Line	:	1930 ILFIELD RD SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87105-7055
Country	:	US
Telephone Number	:	505-249-2023
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 ILFIELD RD SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87105-7055
Country	:	US
Telephone Number	:	505-249-2023
Fax Number	:

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

Provider Enumeration Date	:	07/10/2012
Last Update Date	:	07/10/2012

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