| Organization Name: | FOUR CORNERS MENTAL AND BEHAVIORAL HEALTH PC |
| NPI Number: | 1891056909 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RANDOLPH P BACA (PRESIDENT) |
| Mailing Address: | 6666 4th St Nw Los Ranchos |
| State: | NM US |
| Postal Code: | 871076144 |
| Phone Number: | 5055045505 |
| Fax Number: | 5052145614 |
| NPI Enumeration Date: | 06/05/2012 |
| NPI Last Update Date: | 11/16/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101Y00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider who is trained and educated in the performance of behavior health services through interpersonal communications and analysis. Training and education at the specialty level usually requires a master |