Provider Demographics
NPI:1467822551
Name:BACA, SHERLYN (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:SHERLYN
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 WASHINGTON ST NE
Mailing Address - Street 2:STE A1
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1817 WELLSPRING AVE SE STE D
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4956
Practice Address - Country:US
Practice Address - Phone:505-828-3837
Practice Address - Fax:877-828-1550
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1-18-33057103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst