Provider Demographics
NPI:1578555397
Name:BUCKINGHAM, DWAYNE LAMONT (MSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:LAMONT
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9524 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723
Mailing Address - Country:US
Mailing Address - Phone:210-382-2672
Mailing Address - Fax:
Practice Address - Street 1:9524 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-1816
Practice Address - Country:US
Practice Address - Phone:210-382-2672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060294831041C0700X
MI68010763111041C0700X
MD226981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical