Provider Demographics
NPI:1568553717
Name:BACA, TERRI NIALS (MS CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:NIALS
Last Name:BACA
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S AVENUE K
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7400
Mailing Address - Country:US
Mailing Address - Phone:575-562-4455
Mailing Address - Fax:
Practice Address - Street 1:1500 S. AVE K
Practice Address - Street 2:REGIONAL EDUCATION COOPERATIVE 6
Practice Address - City:PORTTALES
Practice Address - State:NM
Practice Address - Zip Code:88130
Practice Address - Country:US
Practice Address - Phone:575-562-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1176235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist