Healthcare Provider Details

I. General information

NPI: 1154530608
Provider Name (Legal Business Name): LINDA G BUCKLEY MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 N MAIN ST STE J
FT BRAGG CA
95437
US

IV. Provider business mailing address

32350 NAMELESS LANE
FT BRAGG CA
95437
US

V. Phone/Fax

Practice location:
  • Phone: 707-964-7236
  • Fax:
Mailing address:
  • Phone: 707-964-6680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC35067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: