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NPI Code Detail

MEDICARE: MARTICA LOURDES BACALLAO PH.D. LCSW

MEDICARE: MARTICA LOURDES BACALLAO PH.D. LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health CounselorC015288NC

General Provider Information

NPI Number : 1649031022
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARTICA LOURDES BACALLAO PH.D. LCSW
Provider Business Mailing Address
First Line : 900 N CHESTNUT ST
Second Line :
City : LUMBERTON
State : NC
Zip : 28358-4854
Country : US
Telephone Number : 910-739-3064
Fax Number :
Provider Business Practice Location Address
First Line : 900 N CHESTNUT ST
Second Line :
City : LUMBERTON
State : NC
Zip : 28358-4854
Country : US
Telephone Number : 910-739-3064
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/22/2024
Last Update Date : 06/05/2026

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