Provider Demographics
NPI:1275091225
Name:BUCKNER, EVAN
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 W HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9329
Mailing Address - Country:US
Mailing Address - Phone:517-367-0670
Mailing Address - Fax:
Practice Address - Street 1:2950 W HOWELL RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:MI
Practice Address - Zip Code:48854-9329
Practice Address - Country:US
Practice Address - Phone:517-367-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511152091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical