Provider Demographics
NPI:1255840187
Name:BUCCHIANERI, MICHAELA MARIE (PHD, LP)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:MARIE
Last Name:BUCCHIANERI
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 WHITEWATER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-4157
Mailing Address - Country:US
Mailing Address - Phone:952-999-6097
Mailing Address - Fax:952-426-0508
Practice Address - Street 1:12301 WHITEWATER DR STE 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-4157
Practice Address - Country:US
Practice Address - Phone:952-999-6097
Practice Address - Fax:952-426-0508
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6153103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1255840187Medicaid