Provider Demographics
NPI:1588319578
Name:BACON, TROY (BA,IS,CS)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:BA,IS,CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 E HUNTER DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-3481
Mailing Address - Country:US
Mailing Address - Phone:208-996-9795
Mailing Address - Fax:
Practice Address - Street 1:1035 E HUNTER DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-3481
Practice Address - Country:US
Practice Address - Phone:208-996-9795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician