Provider Demographics
NPI:1093145815
Name:BUCKLEY, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 BOYLSTON ST STE 191L
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-3604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 BOYLSTON ST STE 191L
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3604
Practice Address - Country:US
Practice Address - Phone:617-302-7102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2020-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2288838163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse