Provider Demographics
NPI:1649031022
Name:BACALLAO, MARTICA (PHD LCSW)
Entity type:Individual
Prefix:
First Name:MARTICA
Middle Name:
Last Name:BACALLAO
Suffix:
Gender:F
Credentials:PHD LCSW
Other - Prefix:
Other - First Name:MARTICA
Other - Middle Name:
Other - Last Name:KRAEMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:900 N CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-4854
Mailing Address - Country:US
Mailing Address - Phone:910-739-3064
Mailing Address - Fax:
Practice Address - Street 1:900 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-4854
Practice Address - Country:US
Practice Address - Phone:910-739-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC015288101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health