Provider Demographics
NPI:1811056930
Name:BUCKNER, KELLIE NAKATSU (LMFT, EDS)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:NAKATSU
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:LMFT, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NEWFORT PL
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5985
Mailing Address - Country:US
Mailing Address - Phone:864-434-0750
Mailing Address - Fax:877-991-7982
Practice Address - Street 1:28 PARKWAY COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-5213
Practice Address - Country:US
Practice Address - Phone:864-434-0750
Practice Address - Fax:877-991-7982
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
SC4510106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health