Provider Demographics
NPI:1134596430
Name:BUCKLEY, RUTH
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:BUCKLEY
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 1:8849 HIGHWAY 5 STE L
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1500
Mailing Address - Country:US
Mailing Address - Phone:404-907-5542
Mailing Address - Fax:678-550-9216
Practice Address - Street 1:2959 CHAPEL HILL RD STE D118
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1785
Practice Address - Country:US
Practice Address - Phone:404-907-5542
Practice Address - Fax:678-550-9216
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA725081251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services