Provider Demographics
NPI:1679340897
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:
Authorized Official - Phone:415-457-6966
Mailing Address - Street 1:201 ALAMEDA DEL PRADO STE 103
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-6698
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:983 SONOMA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4818
Practice Address - Country:US
Practice Address - Phone:707-583-5284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BUCKELEW PROGRAMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-12-07
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health