Provider Demographics
NPI:1669149357
Name:BUCKHANNON, MAGGIE (SLP)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:
Last Name:BUCKHANNON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 N TRAVERSE MOUNTAIN BLVD APT 14208
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2643
Mailing Address - Country:US
Mailing Address - Phone:702-506-5760
Mailing Address - Fax:
Practice Address - Street 1:5770 S. FASHION BLVD.
Practice Address - Street 2:BLDG 5 SUITE 210
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-314-5232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12369574-4104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist