Provider Demographics
NPI:1871957548
Name:BACA, EDWARD (LPCC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:BACA
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FRIEDMAN AVE
Mailing Address - Street 2:3695 HOT SPRINGS BLVD
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4231
Mailing Address - Country:US
Mailing Address - Phone:505-454-5120
Mailing Address - Fax:505-454-0397
Practice Address - Street 1:700 FRIEDMAN AVE
Practice Address - Street 2:3695 HOT SPRINGS BLVD
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4231
Practice Address - Country:US
Practice Address - Phone:505-454-5120
Practice Address - Fax:505-454-0397
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0149351101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health