Provider Demographics
NPI:1457565335
Name:BACA, CECILIA (MASTER'S)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:MASTER'S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 CENTRAL AVE SW STE 12
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2803
Mailing Address - Country:US
Mailing Address - Phone:505-582-3061
Mailing Address - Fax:
Practice Address - Street 1:2715 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1329
Practice Address - Country:US
Practice Address - Phone:505-242-4533
Practice Address - Fax:505-242-4240
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0135821101YM0800X
NMCCMH0135821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMLADACOther005628
NMT-0098461OtherLMHC