Provider Demographics
NPI:1154581460
Name:BACCHUS, MARCELLA LYDIA (MA,LPC,CAAC)
Entity type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:LYDIA
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:MA,LPC,CAAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 S KALAMAZOO MALL
Mailing Address - Street 2:SUITE 250
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-4877
Mailing Address - Country:US
Mailing Address - Phone:269-383-1440
Mailing Address - Fax:269-383-9781
Practice Address - Street 1:157 S KALAMAZOO MALL
Practice Address - Street 2:SUITE 250
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-4877
Practice Address - Country:US
Practice Address - Phone:269-383-1440
Practice Address - Fax:269-383-9781
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010069101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional