Provider Demographics
NPI:1417187188
Name:BUCKLEY, LAURENCE DANIEL (MCP)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:DANIEL
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:MCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 QUAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-2809
Mailing Address - Country:US
Mailing Address - Phone:580-233-0943
Mailing Address - Fax:
Practice Address - Street 1:605 W OXFORD AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-1208
Practice Address - Country:US
Practice Address - Phone:580-233-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)