Provider Demographics
NPI:1710683933
Name:BUCKNER, OLIVIA (CSW)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 S 600 E STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1028
Mailing Address - Country:US
Mailing Address - Phone:801-906-0525
Mailing Address - Fax:
Practice Address - Street 1:60 S 600 E STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1028
Practice Address - Country:US
Practice Address - Phone:801-906-0525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT122670323502OtherSTATE OF UTAH DEPARTMENT OF COMMERCE