Provider Demographics
NPI:1225120306
Name:BUCKLEY, TODD CHARLES (PHD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:CHARLES
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 SPRAGUE ST
Mailing Address - Street 2:
Mailing Address - City:NORTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01534-1029
Mailing Address - Country:US
Mailing Address - Phone:508-234-4375
Mailing Address - Fax:508-435-2011
Practice Address - Street 1:169 W MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:HOPKINTON
Practice Address - State:MA
Practice Address - Zip Code:01748-2175
Practice Address - Country:US
Practice Address - Phone:508-435-3066
Practice Address - Fax:508-435-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7869103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW51519Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST