Provider Demographics
NPI:1083262430
Name:BACA, ANDREA MARIE (CPSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:BACA
Suffix:
Gender:F
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1374 HIGHWAY 313
Mailing Address - Street 2:
Mailing Address - City:ALGODONES
Mailing Address - State:NM
Mailing Address - Zip Code:87001-8001
Mailing Address - Country:US
Mailing Address - Phone:505-305-8143
Mailing Address - Fax:
Practice Address - Street 1:4730 BECKNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3691
Practice Address - Country:US
Practice Address - Phone:505-989-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X
NM175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist