Provider Demographics
NPI:1316036437
Name:BUCKNER, ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-6202
Mailing Address - Country:US
Mailing Address - Phone:781-239-3550
Mailing Address - Fax:781-239-3272
Practice Address - Street 1:372 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-6202
Practice Address - Country:US
Practice Address - Phone:781-239-3550
Practice Address - Fax:781-239-3272
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6888103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW05625OtherBCBSMA
MA792461OtherTUFTS HEALTH PLAN
MAW05625OtherBCBSMA