Provider Demographics
NPI:1356020291
Name:C DE BACA, MARISA (LMSW)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:C DE BACA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 MEADOWLARK LN SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1021
Mailing Address - Country:US
Mailing Address - Phone:505-927-1024
Mailing Address - Fax:505-988-7328
Practice Address - Street 1:4210 MEADOWLARK LN SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1021
Practice Address - Country:US
Practice Address - Phone:505-927-1024
Practice Address - Fax:505-988-7328
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-0633104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker