Provider Demographics
NPI:1144855925
Name:BACA VILLAGOMEZ, VICTORIA LUJAN (LMHC)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LUJAN
Last Name:BACA VILLAGOMEZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 NE 5TH TER APT 618
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2504
Mailing Address - Country:US
Mailing Address - Phone:480-760-1431
Mailing Address - Fax:
Practice Address - Street 1:501 NE 5TH TER APT 618
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2504
Practice Address - Country:US
Practice Address - Phone:480-760-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH17433101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty