Provider Demographics
NPI:1336428317
Name:BACON, AKILA FANA
Entity Type:Individual
Prefix:
First Name:AKILA
Middle Name:FANA
Last Name:BACON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 EXPLORER WAY
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93552-3454
Mailing Address - Country:US
Mailing Address - Phone:818-523-2379
Mailing Address - Fax:
Practice Address - Street 1:1529 E PALMDALE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-2029
Practice Address - Country:US
Practice Address - Phone:818-523-2379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2023-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF73718101YM0800X
CAAMFT110989101YM0800X
CALMFT139465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health