Provider Demographics
NPI:1942577952
Name:MCCALLA, CANDACE ALEXIS (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:ALEXIS
Last Name:MCCALLA
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 HUNTER AVE APT 26F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-5658
Mailing Address - Country:US
Mailing Address - Phone:917-693-8316
Mailing Address - Fax:
Practice Address - Street 1:2440 HUNTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-5646
Practice Address - Country:US
Practice Address - Phone:917-693-8316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0797421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04686848Medicaid
NY4741862OtherEMBLEM HEALTH/GHI PROVIDER