Provider Demographics
NPI:1710509377
Name:MARY KAY BUCKLEY, PSYCHOTHERAPIST INC
Entity Type:Organization
Organization Name:MARY KAY BUCKLEY, PSYCHOTHERAPIST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:BUCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:559-250-6715
Mailing Address - Street 1:1357 W SHAW AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3619
Mailing Address - Country:US
Mailing Address - Phone:559-250-6715
Mailing Address - Fax:
Practice Address - Street 1:1357 W SHAW AVE STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3619
Practice Address - Country:US
Practice Address - Phone:559-250-6715
Practice Address - Fax:866-812-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-17
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7246041Medicaid