Provider Demographics
NPI:1275964041
Name:BACUS, JUDY DANIELLE
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:DANIELLE
Last Name:BACUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:DANIELLE
Other - Last Name:BACUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1624 SANTA CLARA DR STE 145
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3500
Mailing Address - Country:US
Mailing Address - Phone:916-779-2455
Mailing Address - Fax:916-588-2880
Practice Address - Street 1:1624 SANTA CLARA DR STE 145
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3500
Practice Address - Country:US
Practice Address - Phone:916-779-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator