Provider Demographics
NPI:1912449646
Name:BACA, MICHELLE (LISW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 GOLD AVE SW
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3202
Mailing Address - Country:US
Mailing Address - Phone:505-247-4900
Mailing Address - Fax:505-933-6373
Practice Address - Street 1:320 GOLD AVE SW
Practice Address - Street 2:SUITE 1001
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3202
Practice Address - Country:US
Practice Address - Phone:505-247-4900
Practice Address - Fax:505-933-6373
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-07571104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker