Healthcare Provider Details

I. General information

NPI: 1912128349
Provider Name (Legal Business Name): MARY LEE BUCKMAN L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E 1100 N
CHESTERTON IN
46304-9349
US

IV. Provider business mailing address

75 E 1100 N
CHESTERTON IN
46304-9349
US

V. Phone/Fax

Practice location:
  • Phone: 219-928-3695
  • Fax: 219-926-7318
Mailing address:
  • Phone: 219-928-3695
  • Fax: 219-926-7318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000790A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: