Provider Demographics
NPI:1568404309
Name:BUCKLEY, STANLEY (LMSW, RAODAC)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:LMSW, RAODAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3602
Mailing Address - Country:US
Mailing Address - Phone:316-660-7600
Mailing Address - Fax:316-383-7925
Practice Address - Street 1:1929 W 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-2106
Practice Address - Country:US
Practice Address - Phone:316-660-7700
Practice Address - Fax:316-838-2115
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0053101YA0400X
KS2796104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4137OtherPREFERRED HEALTH SYSTEMS
KS389906OtherBLUE CROSS BLUE SHIELD