Provider Demographics
NPI:1649587874
Name:BUCKELEW PROGRAM
Entity Type:Organization
Organization Name:BUCKELEW PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR SITE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-457-6964
Mailing Address - Street 1:900 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2959
Mailing Address - Country:US
Mailing Address - Phone:415-457-6964
Mailing Address - Fax:
Practice Address - Street 1:900 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2959
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty