Healthcare Provider Details

I. General information

NPI: 1922516889
Provider Name (Legal Business Name): MICHAEL ANTHONY BACALLAO LMSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 N MCKELVY AVE APT 202
CLOVIS CA
93611-2410
US

IV. Provider business mailing address

64S MANOR CRES
NEW BRUNSWICK NJ
08901-1645
US

V. Phone/Fax

Practice location:
  • Phone: 732-425-5851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06183100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: