Provider Demographics
NPI:1023661659
Name:BACALSO, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BACALSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 N IRONWOOD RD
Mailing Address - Street 2:SUITE 202 PMB 1013
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2416
Mailing Address - Country:US
Mailing Address - Phone:414-367-4447
Mailing Address - Fax:
Practice Address - Street 1:13111 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53097-2416
Practice Address - Country:US
Practice Address - Phone:262-243-6127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131474-1211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty