Provider Demographics
NPI:1205241858
Name:BUCKLEY, SHANNON MARIE (CDCA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 N CANFIELD NILES RD
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-2343
Mailing Address - Country:US
Mailing Address - Phone:330-270-2380
Mailing Address - Fax:
Practice Address - Street 1:45 N CANFIELD NILES RD
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2343
Practice Address - Country:US
Practice Address - Phone:330-270-2380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401123830710374U00000X
OHCDCA.163020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080934Medicaid