Provider Demographics
NPI:1083262430
Name:BACA, ANDREA MARIE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:BACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1374 HIGHWAY 313
Mailing Address - Street 2:
Mailing Address - City:ALGODONES
Mailing Address - State:NM
Mailing Address - Zip Code:87001-8001
Mailing Address - Country:US
Mailing Address - Phone:505-305-8143
Mailing Address - Fax:
Practice Address - Street 1:1217 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1529
Practice Address - Country:US
Practice Address - Phone:505-766-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
NM175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist