Provider Demographics
NPI:1629541149
Name:BUCKLER, BROOKE M
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:M
Last Name:BUCKLER
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 1:43 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMELIA
Mailing Address - State:OH
Mailing Address - Zip Code:45102-1993
Mailing Address - Country:US
Mailing Address - Phone:513-947-7161
Mailing Address - Fax:513-947-7050
Practice Address - Street 1:1501 MADISON RD
Practice Address - Street 2:
Practice Address - City:WALNUT HILLS
Practice Address - State:OH
Practice Address - Zip Code:45206-1706
Practice Address - Country:US
Practice Address - Phone:513-354-5200
Practice Address - Fax:513-354-7115
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000OtherLICENSURE BOARD