Provider Demographics
NPI:1710160320
Name:BUCKENHAM, EDWARD GERARD III (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:GERARD
Last Name:BUCKENHAM
Suffix:III
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 ROYAL OAK DR NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-9331
Mailing Address - Country:US
Mailing Address - Phone:706-295-0440
Mailing Address - Fax:
Practice Address - Street 1:104 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3128
Practice Address - Country:US
Practice Address - Phone:706-235-6990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001620101YP2500X
GALPC006095101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional