Provider Demographics
NPI:1023499027
Name:BACA, DESIREE (BSW)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 COLUMBINE CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6453
Mailing Address - Country:US
Mailing Address - Phone:307-256-0136
Mailing Address - Fax:
Practice Address - Street 1:1403 COLUMBINE CT
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-6453
Practice Address - Country:US
Practice Address - Phone:307-256-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator