Provider Demographics
NPI:1922516889
Name:BACALLAO, MICHAEL ANTHONY (LMSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:BACALLAO
Suffix:
Gender:M
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64S MANOR CRES
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:382 N MCKELVY AVE APT 202
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-2410
Practice Address - Country:US
Practice Address - Phone:732-425-5851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC061831001041C0700X
CA1157001041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical