Provider Demographics
NPI:1134332463
Name:BUCKENMEYER, ERIC JOSEPH (LCSW)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:JOSEPH
Last Name:BUCKENMEYER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3473 TROPHY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-8011
Mailing Address - Country:US
Mailing Address - Phone:619-589-8073
Mailing Address - Fax:619-589-8073
Practice Address - Street 1:4700 SPRING ST
Practice Address - Street 2:SUITE 306
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5263
Practice Address - Country:US
Practice Address - Phone:619-589-0256
Practice Address - Fax:619-469-4515
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA164541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW164540Medicaid
CASW16454AMedicare ID - Type UnspecifiedPROVIDER NUMBER