Provider Demographics
NPI:1710532023
Name:BACA ELLER, LOUISE M (PHD)
Entity Type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:M
Last Name:BACA ELLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LOUISE
Other - Middle Name:M
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2940 E BANNER GATEWAY DRIVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-3682
Practice Address - Street 1:2946 E. BANNER GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-3682
Is Sole Proprietor?:No
Enumeration Date:2019-08-04
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical