Provider Demographics
NPI:1811015837
Name:BACA, MARY JO RANELLS (LMSW, MPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:RANELLS
Last Name:BACA
Suffix:
Gender:F
Credentials:LMSW, MPH
Other - Prefix:
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Mailing Address - Street 1:617 EDITH BLVD NE
Mailing Address - Street 2:#5
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2570
Mailing Address - Country:US
Mailing Address - Phone:505-239-9369
Mailing Address - Fax:
Practice Address - Street 1:2112 MAIN ST NE
Practice Address - Street 2:SUITE A
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6353
Practice Address - Country:US
Practice Address - Phone:505-865-6176
Practice Address - Fax:505-865-3268
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-060421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical