Provider Demographics
NPI:1821562414
Name:BACA, EDNA (LPC)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 LOCKHILL SELMA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1559
Mailing Address - Country:US
Mailing Address - Phone:210-254-3618
Mailing Address - Fax:
Practice Address - Street 1:1842 LOCKHILL SELMA RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-1559
Practice Address - Country:US
Practice Address - Phone:210-254-3618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional