Provider Demographics
NPI:1174867170
Name:BUCKNELL, CALLY
Entity Type:Individual
Prefix:
First Name:CALLY
Middle Name:
Last Name:BUCKNELL
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 1:300 TACONITE ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HURLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54534-1546
Mailing Address - Country:US
Mailing Address - Phone:715-561-3636
Mailing Address - Fax:
Practice Address - Street 1:300 TACONITE ST
Practice Address - Street 2:SUITE 201
Practice Address - City:HURLEY
Practice Address - State:WI
Practice Address - Zip Code:54534-1546
Practice Address - Country:US
Practice Address - Phone:715-561-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15674-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)