Healthcare Provider Details

I. General information

NPI: 1043895121
Provider Name (Legal Business Name): MR. DANIEL THOMAS BUKACEL JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16645 15 MILE RD
CLINTON TWP MI
48035-2206
US

IV. Provider business mailing address

16645 15 MILE RD
CLINTON TWP MI
48035-2206
US

V. Phone/Fax

Practice location:
  • Phone: 586-213-5505
  • Fax:
Mailing address:
  • Phone: 586-213-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451022246
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: