Provider Demographics
NPI:1215168257
Name:BACA, STEPHANIE L (PT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:BACA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 RIDGECREST DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-4437
Mailing Address - Country:US
Mailing Address - Phone:505-250-7049
Mailing Address - Fax:
Practice Address - Street 1:1612 RIDGECREST DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4437
Practice Address - Country:US
Practice Address - Phone:505-250-7049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Q0406Medicaid
NM1386651412OtherBILLING NPI
NM1386651412OtherBILLING NPI
NM900521078Medicare PIN