Healthcare Provider Details

I. General information

NPI: 1073204053
Provider Name (Legal Business Name): EMILY BUCKELEW MA, MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E BUTTERFIELD RD STE 212
LOMBARD IL
60148-4879
US

IV. Provider business mailing address

477 E BUTTERFIELD RD STE 212
LOMBARD IL
60148-4879
US

V. Phone/Fax

Practice location:
  • Phone: 630-866-5666
  • Fax:
Mailing address:
  • Phone: 630-866-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178019114
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: