Provider Demographics
NPI:1518105758
Name:BACCAM, MARSHA LA (MSW)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:LA
Last Name:BACCAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 BRIDGEWATER CIR
Mailing Address - Street 2:APT. A
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-7352
Mailing Address - Country:US
Mailing Address - Phone:321-482-2814
Mailing Address - Fax:
Practice Address - Street 1:100 SAW MILL RD
Practice Address - Street 2:SUITE 3200
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-5592
Practice Address - Country:US
Practice Address - Phone:765-742-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33005400A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker