Provider Demographics
NPI:1568786770
Name:BUCKINGHAM, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1876 S SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6136
Mailing Address - Country:US
Mailing Address - Phone:307-672-0475
Mailing Address - Fax:307-674-6867
Practice Address - Street 1:1876 S SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6136
Practice Address - Country:US
Practice Address - Phone:307-672-0475
Practice Address - Fax:307-674-6867
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY340101YA0400X
ND49751041C0700X, 1041C0700X
WY6341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)