Basic Information
| Provider Information | |||||||||
| NPI: | 1972993616 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKELEW PROGRAMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 ALAMEDA DEL PRADO STE 103 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949496698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154576964 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 ALAMEDA DEL PRADO STE 103 | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949496698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154576964 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | KUGHN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4154576966 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.