Provider Demographics
NPI:1316162894
Name:BACON, LAURA LEE (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:BACON
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 1:2105 PASEO DEL MONTE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-6320
Mailing Address - Country:US
Mailing Address - Phone:505-982-7783
Mailing Address - Fax:
Practice Address - Street 1:1751 OLD PECOS TRAIL
Practice Address - Street 2:SUITE M
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-989-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM19062251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic