Provider Demographics
NPI:1609644848
Name:BUCKELEW PROGRAMS
Entity Type:Organization
Organization Name:BUCKELEW PROGRAMS
Other - Org Name:BUCKELEW COMMUNITY RESPONSE TEAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:KUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:415-457-6966
Mailing Address - Street 1:2235 MERCURY WAY STE 107
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5472
Mailing Address - Country:US
Mailing Address - Phone:707-780-7239
Mailing Address - Fax:
Practice Address - Street 1:2235 MERCURY WAY STE 107
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5472
Practice Address - Country:US
Practice Address - Phone:707-780-7239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUCKELEW PROGRAMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health