Provider Demographics
NPI:1154039741
Name:BACA, MERCEDES (DT)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 S OAKLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4313
Mailing Address - Country:US
Mailing Address - Phone:312-375-4151
Mailing Address - Fax:
Practice Address - Street 1:1014 S OAKLEY BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4313
Practice Address - Country:US
Practice Address - Phone:312-375-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist