Provider Demographics
NPI:1326199654
Name:BUCKLES, SUSAN I (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:I
Last Name:BUCKLES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4673
Mailing Address - Street 2:
Mailing Address - City:ROLLINGBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98061-0673
Mailing Address - Country:US
Mailing Address - Phone:206-842-5871
Mailing Address - Fax:
Practice Address - Street 1:180 ERICKSEN AVE NE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1858
Practice Address - Country:US
Practice Address - Phone:206-842-5871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000045471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical