MEDICARE: PATRICIA A BACA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor		NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902503931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA A BACA

Provider Business Mailing Address
First Line	:	105 PASEO DEL CANON W STE A
Second Line	:
City	:	TAOS
State	:	NM
Zip	:	87571-6943
Country	:	US
Telephone Number	:	575-737-5533
Fax Number	:	575-737-5534

Provider Business Practice Location Address
First Line	:	2301 7TH ST STE A
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4966
Country	:	US
Telephone Number	:	505-454-9611
Fax Number	:	505-454-8079

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

Provider Enumeration Date	:	02/09/2023
Last Update Date	:	01/04/2026

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