Provider Demographics
NPI:1306242474
Name:BACA, MEREDITH (LPCC, LPC)
Entity type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:LPCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:OHKAY OWINGEH
Mailing Address - State:NM
Mailing Address - Zip Code:87566-1045
Mailing Address - Country:US
Mailing Address - Phone:210-593-8552
Mailing Address - Fax:
Practice Address - Street 1:360 FOG ROAD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:210-862-1037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68716101YM0800X
NMCCMH200151101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health