Provider Demographics
NPI:1962685446
Name:BUCKLEW, JOHN EDD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDD
Last Name:BUCKLEW
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 1:600 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1753
Mailing Address - Country:US
Mailing Address - Phone:573-592-2796
Mailing Address - Fax:
Practice Address - Street 1:600 E 5TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1753
Practice Address - Country:US
Practice Address - Phone:573-592-2796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00975103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist