Provider Demographics
NPI:1336856756
Name:BACULIS, MELISSA (LSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BACULIS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 CHELSEA CT
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08823-1503
Mailing Address - Country:US
Mailing Address - Phone:908-566-8745
Mailing Address - Fax:
Practice Address - Street 1:104 BAYARD ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2389
Practice Address - Country:US
Practice Address - Phone:908-566-8745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06675800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker