Provider Demographics
NPI:1184122152
Name:BUCCALO, NICOLE (LLMSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BUCCALO
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25529 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1749
Mailing Address - Country:US
Mailing Address - Phone:248-302-1051
Mailing Address - Fax:
Practice Address - Street 1:1600 PORTER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48216-1936
Practice Address - Country:US
Practice Address - Phone:248-302-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102176104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker