Provider Demographics
NPI:1720131782
Name:BUCKLES-SMITH, SONJA R (LCMHCS)
Entity Type:Individual
Prefix:MRS
First Name:SONJA
Middle Name:R
Last Name:BUCKLES-SMITH
Suffix:
Gender:F
Credentials:LCMHCS
Other - Prefix:MRS
Other - First Name:SONJA
Other - Middle Name:ROCHELLE
Other - Last Name:BUCKLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, LPCS
Mailing Address - Street 1:2722 IMPATIEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215
Mailing Address - Country:US
Mailing Address - Phone:704-773-3956
Mailing Address - Fax:704-919-0474
Practice Address - Street 1:2210 CORONATION BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:704-773-3956
Practice Address - Fax:704-919-0474
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-20
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCS9891101YM0800X
NC9891101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD005959500Medicaid
NC6115145Medicaid