Provider Demographics
NPI:1083790455
Name:BUCKNER, CAROL RUTH (LCPC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:RUTH
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E NORRIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-3678
Mailing Address - Country:US
Mailing Address - Phone:815-434-4382
Mailing Address - Fax:815-431-5528
Practice Address - Street 1:1100 E NORRIS DRIVE
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-3678
Practice Address - Country:US
Practice Address - Phone:815-434-4382
Practice Address - Fax:815-431-5528
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional