Provider Demographics
NPI:1588106785
Name:BACA, CHELSEY (ATC, LAT)
Entity type:Individual
Prefix:
First Name:CHELSEY
Middle Name:
Last Name:BACA
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17374 N 89TH AVE APT 1326
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8139
Mailing Address - Country:US
Mailing Address - Phone:602-703-3194
Mailing Address - Fax:
Practice Address - Street 1:9126 W CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-3116
Practice Address - Country:US
Practice Address - Phone:602-703-3194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-06
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20000227612255A2300X
AZ14262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer