Provider Demographics
NPI:1942211255
Name:BUCKLEY, STEPHEN W (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:W
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EXECUTIVE BLVD
Mailing Address - Street 2:SUITE #109
Mailing Address - City:MONTEBELLO
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4180
Mailing Address - Country:US
Mailing Address - Phone:845-304-5082
Mailing Address - Fax:
Practice Address - Street 1:1 EXECUTIVE BLVD
Practice Address - Street 2:SUITE #109
Practice Address - City:MONTEBELLO
Practice Address - State:NY
Practice Address - Zip Code:10901-4180
Practice Address - Country:US
Practice Address - Phone:845-304-5082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013762103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01983417Medicaid
NYV82771Medicare PIN