Provider Demographics
NPI:1275984825
Name:BACA, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
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 1:2015 PIONEER CT
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1781
Mailing Address - Country:US
Mailing Address - Phone:650-342-0454
Mailing Address - Fax:650-342-0554
Practice Address - Street 1:27 N HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-2923
Practice Address - Country:US
Practice Address - Phone:650-342-0454
Practice Address - Fax:650-342-0554
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)