Provider Demographics
NPI:1356808661
Name:BUCKNER, MARY ANNA (RBT-18-73005)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNA
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:RBT-18-73005
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 HAZELNUT ST
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-6732
Mailing Address - Country:US
Mailing Address - Phone:386-864-9391
Mailing Address - Fax:386-226-2076
Practice Address - Street 1:1288 HAZELNUT ST
Practice Address - Street 2:
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-6732
Practice Address - Country:US
Practice Address - Phone:386-864-9391
Practice Address - Fax:386-226-2076
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-73005106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician