Provider Demographics
NPI:1467264135
Name:BUCKWALTER, LAURA JEAN
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:BUCKWALTER
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 1:4687 KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3209
Mailing Address - Country:US
Mailing Address - Phone:717-380-1487
Mailing Address - Fax:
Practice Address - Street 1:2755 55TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5043
Practice Address - Country:US
Practice Address - Phone:619-493-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25-403034106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician