Provider Demographics
NPI:1811374465
Name:EDMONDS BUCKLEY, ANTANIQUE REVESHA (LICSW, LCSW)
Entity Type:Individual
Prefix:
First Name:ANTANIQUE
Middle Name:REVESHA
Last Name:EDMONDS BUCKLEY
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:ANTANIQUE
Other - Middle Name:
Other - Last Name:BUCKLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:9868 SOFTWATER WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1825
Mailing Address - Country:US
Mailing Address - Phone:443-583-4421
Mailing Address - Fax:
Practice Address - Street 1:9868 SOFTWATER WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1825
Practice Address - Country:US
Practice Address - Phone:443-583-4421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2023-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096954104100000X
DCLC5008258251041C0700X
VA09040147201041C0700X
1041C0700X
MD261731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker