Healthcare Provider Details

I. General information

NPI: 1023898996
Provider Name (Legal Business Name): KIMBERLY R BUCKLEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 10/15/2023
Certification Date: 10/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3825 GREENSPRING AVE
BALTIMORE MD
21211-1310
US

IV. Provider business mailing address

3825 GREENSPRING AVE
BALTIMORE MD
21211-1310
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-7800
  • Fax:
Mailing address:
  • Phone: 443-923-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number30484
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number30484
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number30484
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: