Provider Demographics
NPI:1639681406
Name:BUCKELEW, BRADLEY (RBT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BUCKELEW
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6188 HALF MOON DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-1124
Mailing Address - Country:US
Mailing Address - Phone:386-589-8357
Mailing Address - Fax:
Practice Address - Street 1:823 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4220
Practice Address - Country:US
Practice Address - Phone:386-589-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst