Provider Demographics
NPI:1528325131
Name:BACON, EMILY SPENCE (BA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:SPENCE
Last Name:BACON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 SKY MOUNTAIN DR
Mailing Address - Street 2:APT 1421
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-9193
Mailing Address - Country:US
Mailing Address - Phone:775-790-1622
Mailing Address - Fax:
Practice Address - Street 1:63 KEYSTONE AVE STE 304
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5524
Practice Address - Country:US
Practice Address - Phone:775-333-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1780899724Medicaid