Provider Demographics
NPI:1942481171
Name:BUCKLES, MARISSA S
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:S
Last Name:BUCKLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-7011
Mailing Address - Country:US
Mailing Address - Phone:510-252-0910
Mailing Address - Fax:510-252-0428
Practice Address - Street 1:588 BROWN RD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-7011
Practice Address - Country:US
Practice Address - Phone:510-252-0910
Practice Address - Fax:510-252-0428
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator