Provider Demographics
NPI:1205656402
Name:BACCHUS, AMELO (LAC)
Entity type:Individual
Prefix:
First Name:AMELO
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 POLK ST APT O3
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-2880
Mailing Address - Country:US
Mailing Address - Phone:862-218-7755
Mailing Address - Fax:
Practice Address - Street 1:67 SANFORD ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-1926
Practice Address - Country:US
Practice Address - Phone:973-673-3342
Practice Address - Fax:973-673-5612
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00826000101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health