Provider Demographics
NPI:1568660314
Name:BUCKLEY, PATRICIA KERSULIS (LAC)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:KERSULIS
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:850 N MAIN STREET EXT
Mailing Address - Street 2:BLDG 2, SUITE 3B
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2400
Mailing Address - Country:US
Mailing Address - Phone:203-284-8661
Mailing Address - Fax:203-284-1050
Practice Address - Street 1:850 N MAIN STREET EXT
Practice Address - Street 2:BLDG 2, SUITE 3B
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2400
Practice Address - Country:US
Practice Address - Phone:203-284-8661
Practice Address - Fax:203-284-1050
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000203171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist