Provider Demographics
NPI:1396229639
Name:BACCO, MARK A (MA, LPC, LCADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BACCO
Suffix:
Gender:M
Credentials:MA, LPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LEWISBURG RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:NJ
Mailing Address - Zip Code:07848-3145
Mailing Address - Country:US
Mailing Address - Phone:973-224-4888
Mailing Address - Fax:
Practice Address - Street 1:4 GOLD MINE RD
Practice Address - Street 2:
Practice Address - City:ROXBURY TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07836-9122
Practice Address - Country:US
Practice Address - Phone:973-527-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-22
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00204100101YA0400X
NJ37PC00564400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)