Provider Demographics
NPI:1134642473
Name:BUCKLAND, CHARIS (LPC)
Entity Type:Individual
Prefix:
First Name:CHARIS
Middle Name:
Last Name:BUCKLAND
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 RIVER TRACE DR
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-5505
Mailing Address - Country:US
Mailing Address - Phone:228-257-7819
Mailing Address - Fax:
Practice Address - Street 1:3781 RIVER TRACE DR
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-5505
Practice Address - Country:US
Practice Address - Phone:228-257-7819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1906101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional