Provider Demographics
NPI:1104033109
Name:BACON, RONALD A (MA, MDIV)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:A
Last Name:BACON
Suffix:
Gender:M
Credentials:MA, MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31952 CAMINO CAPISTRANO
Mailing Address - Street 2:C-23
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3229
Mailing Address - Country:US
Mailing Address - Phone:949-488-8990
Mailing Address - Fax:949-488-9550
Practice Address - Street 1:31952 CAMINO CAPISTRANO
Practice Address - Street 2:C-23
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3229
Practice Address - Country:US
Practice Address - Phone:949-488-8990
Practice Address - Fax:949-488-9550
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 28250106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist