Provider Demographics
NPI:1619145364
Name:BUCKLEY, AIMEE KOCH (MA, CCC/ SLP)
Entity Type:Individual
Prefix:MRS
First Name:AIMEE
Middle Name:KOCH
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:MA, CCC/ SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CHANTICLEER DR
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-6320
Mailing Address - Country:US
Mailing Address - Phone:985-641-2426
Mailing Address - Fax:
Practice Address - Street 1:125 CHANTICLEER DR
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:LA
Practice Address - Zip Code:70452-6320
Practice Address - Country:US
Practice Address - Phone:985-641-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1473413Medicaid