Provider Demographics
NPI:1417404393
Name:BUCKNER, SHARETTA (CDCA)
Entity Type:Individual
Prefix:
First Name:SHARETTA
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 W SOUTH BOUNDARY ST
Mailing Address - Street 2:STE 600
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5234
Mailing Address - Country:US
Mailing Address - Phone:419-873-8280
Mailing Address - Fax:
Practice Address - Street 1:1090 W SOUTH BOUNDARY ST
Practice Address - Street 2:STE 600
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5234
Practice Address - Country:US
Practice Address - Phone:419-873-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.160672101Y00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No251S00000XAgenciesCommunity/Behavioral Health