Provider Demographics
NPI:1679083265
Name:BUCALOS, MARY ANN (MA, LLPC, NCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:BUCALOS
Suffix:
Gender:F
Credentials:MA, LLPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 CASTLEMARTIN CT
Mailing Address - Street 2:
Mailing Address - City:OAKLAND TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4906
Mailing Address - Country:US
Mailing Address - Phone:248-563-2939
Mailing Address - Fax:
Practice Address - Street 1:1200 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1032
Practice Address - Country:US
Practice Address - Phone:248-456-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014551101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional