Provider Demographics
NPI:1992045439
Name:BUCKLEY, MARY KATHLEEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 W SHAW AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3619
Mailing Address - Country:US
Mailing Address - Phone:559-250-6715
Mailing Address - Fax:866-812-5195
Practice Address - Street 1:1357 W SHAW AVE STE 102
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3619
Practice Address - Country:US
Practice Address - Phone:559-250-6715
Practice Address - Fax:866-812-5195
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-20
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW115721041C0700X
CALCS 11572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7246041Medicaid
CAZZZ26585ZOtherBLUE SHIELD OF CALIFORNIA
CACA21889391OtherANTHEM BLUE CROSS