Provider Demographics
NPI:1568408672
Name:BUCKNER, MARCY BETH (LICSW)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:BETH
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:BETH
Other - Last Name:POLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 GOLDEN VALLEY ROAD
Mailing Address - Street 2:COURAGE CENTER
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4298
Mailing Address - Country:US
Mailing Address - Phone:763-520-0463
Mailing Address - Fax:763-520-0355
Practice Address - Street 1:3915 GOLDEN VALLEY ROAD
Practice Address - Street 2:COURAGE CENTER
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4298
Practice Address - Country:US
Practice Address - Phone:763-520-0463
Practice Address - Fax:763-520-0355
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63D31BUOtherBCBS MINNESOTA
963371008127OtherPREFERRED ONE
6236582OtherUBH
HP38889OtherHEALTHPARTNERS