Provider Demographics
NPI:1114569027
Name:BUCKALLEW, KOURTNEY
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:BUCKALLEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2894
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:
Practice Address - Street 1:1101 JAMISON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3943
Practice Address - Country:US
Practice Address - Phone:660-665-1962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor