Provider Demographics
NPI:1508328337
Name:BUCKNER, BENJAMIN LEE (ASW)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LEE
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11175 SAN PABLO AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-2157
Mailing Address - Country:US
Mailing Address - Phone:510-559-5550
Mailing Address - Fax:
Practice Address - Street 1:11175 SAN PABLO AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2157
Practice Address - Country:US
Practice Address - Phone:510-559-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1043561041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical