Provider Demographics
NPI:1265270920
Name:BUFFUM, KEETON
Entity type:Individual
Prefix:
First Name:KEETON
Middle Name:
Last Name:BUFFUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 BAY MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-6612
Mailing Address - Country:US
Mailing Address - Phone:601-405-9011
Mailing Address - Fax:
Practice Address - Street 1:515 SIMPSON DR
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-3009
Practice Address - Country:US
Practice Address - Phone:769-233-7154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSRBT-24-323976106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician