Provider Demographics
NPI:1417715863
Name:BUCKLER, KENNETH M (LICENSED COUNSELOR)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:BUCKLER
Suffix:
Gender:M
Credentials:LICENSED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 E PRIMROSE ST STE A
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4586
Mailing Address - Country:US
Mailing Address - Phone:417-881-8888
Mailing Address - Fax:417-881-8862
Practice Address - Street 1:380 SAINT ROBERT OUTER RD
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3722
Practice Address - Country:US
Practice Address - Phone:573-336-4900
Practice Address - Fax:417-881-8862
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023048417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty