MEDICARE: MS. CANDACE ALEXIS MCCALLA LCSW-R

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
1	1041C0700X	Clinical Social Worker	079742	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4741862	OTHER	NY	EMBLEM HEALTH/GHI PROVIDER

General Provider Information

NPI Number	:	1942577952
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CANDACE ALEXIS MCCALLA LCSW-R

Provider Business Mailing Address
First Line	:	2440 HUNTER AVE APT 26F
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10475-5658
Country	:	US
Telephone Number	:	917-693-8316
Fax Number	:

Provider Business Practice Location Address
First Line	:	2440 HUNTER AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10475-5646
Country	:	US
Telephone Number	:	917-693-8316
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	08/10/2022

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