Healthcare Provider Details

I. General information

NPI: 1508328337
Provider Name (Legal Business Name): BENJAMIN LEE BUCKNER ASW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 07/29/2026
Certification Date: 05/09/2023
Deactivation Date: 06/25/2026
Reactivation Date: 07/29/2026

III. Provider practice location address

11175 SAN PABLO AVE
EL CERRITO CA
94530-2157
US

IV. Provider business mailing address

11175 SAN PABLO AVE
EL CERRITO CA
94530-2157
US

V. Phone/Fax

Practice location:
  • Phone: 510-559-5550
  • Fax:
Mailing address:
  • Phone: 510-559-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number104356
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104356
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: