Provider Demographics
NPI:1437380193
Name:BACA, CRYSTAL S (AUD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:S
Last Name:BACA
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:S
Other - Last Name:CARNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:5005 PROSPECT AVE NE
Mailing Address - Street 2:STE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4275
Mailing Address - Country:US
Mailing Address - Phone:505-247-4466
Mailing Address - Fax:505-247-4472
Practice Address - Street 1:5005 PROSPECT AVE NE
Practice Address - Street 2:STE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4275
Practice Address - Country:US
Practice Address - Phone:505-247-4466
Practice Address - Fax:505-247-4472
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4682231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist